Form 5-6601 Application for Financial Assistance and Social Services

OMB Control No. 1076-0017

Expires: xx/xx/20xx

I NTERVIEW DATE: ____________________

APPLICATION FOR FINANCIAL ASSISTANCE AND SOCIAL SERVICES INSTRUCTIONS

Any individual or family may apply for Bureau of Indian Affairs Financial Assistance and Social Services by completing the application process with the assistance of the Social Services worker and providing the following required information: proof of tribal membership; proof of residency; proof of income and resources. Failing to provide this information may result in denial of Financial Assistance and Social Services.

DIRECTIONS FOR COMPLETING “APPLICATION FOR FINANCIAL ASSISTANCE AND SOCIAL SERVICES” FORM

Please fill in your NAME/TRIBE/PHYSICAL ADDRESS/PHONE NUMBER/MAILING ADDRESS (if different from physical address) or provide directions on how to get to your home. Please also respond to the two questions.

Section I: FAMILY PROFILE OF HEAD OF HOUSEHOLD MEMBERS APPLYING

Under Family Profile, fill in the following information to the best of your ability. First, start with yourself. Please fill in your name (Last, First, Middle), Date of Birth (mm/dd/yyyy), Sex (M/F), your marital status, the highest education level received, Social Security Number, and finally your Tribal Enrollment Number. Next, complete the names of the total members of the household starting with your spouse and then children in descending order of age. For each member list the birth date, sex, and relation to the head of household, marital status, highest education received, Social Security Number, and Tribal Enrollment number. If you are living in a household with more than one (1) family, list the family members that fall under your household.

Section II: TYPES OF FINANCIAL ASSISTANCE AND SOCIAL SERVICES

Put a check mark in the boxes for the services you are applying. This will assist your Social Services worker in determining which portions of the application you will need to complete.

Section III: EARNED & UNEARNED INCOME

All income, including earned and unearned income, for yourself and any other person in your household, is to be listed on the application. You are required to provide proof of income.

Earned Income

is cash or any in-kind payment earned in the form of 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. (25 CFR §20.308)

Unearned Income

includes but is not limited to; interest, royalties, gaming income or other per capita distribution not excluded by federal statue, rental property, cash contributions such as child support or 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. (25 CFR §20.309).

Under Section II and Section III please complete questions 1-4 to the very best of your ability based on the information provided above. If you are unsure of the question please ask your Social Services worker for assistance or clarification.

Section IV: STATEMENT OF COOPERATION

The Statement of Cooperation is a confirmation of your understanding of the provisions of the Federal Law governing fraud, and you agree to supply information regarding resources and income and to notify the agency of any change in your living situation. Also you must sign the Release of Information authorizing the Social Services Program to obtain and/or exchange information necessary to establish eligibility for Financial Assistance and Social Services.

IF YOU NEED CLARIFICATION OR HAVE ANY QUESTIONS, PLEASE ASK YOUR SOCIAL SERVICES WORKER

OMB Control No. 1076-0017 Expires: xx/xx/20xx BIA Form # 5-6601 Revised: 1/14/21

U.S. Department of the Interior Bureau of Indian Affairs Division of Human Services

Date of Application: ____________________________ Date of Interview: ____________________________

Decision: Approved; Date: _________ to _________: _________ Initials

APPLICATION for FINANCIAL ASSISTANCE and SOCIAL SERVICES

Denied; Date: ________________: _________ Initials Reason for Denial:

Date of Redetermination ___________ / ____________

AREAS ARE FOR BIA AGENCY USE ONLY.

Name: ___________________________________________________________________________ Tribe/Enrollment Number:____________________________________ Other Name(s) Used: _________________________________________________________ Phone Number: ________________________________________________ Mailing Address: ___________________________________________________________________________________________________________________________________ Physical Address: _________________________________________________________________ Cell/ MSG Number: _________________________________________ Provide directions on how to get to your home:________________________________________________________________________________________________

1. Reason for applying for Financial Assistance and Social Services?

2. What type of income have you been living on for the last three (3) months?

Section I: FAMILY PROFILE OF HEAD OF HOUSEHOLD MEMBERS APPLYING (25 CFR §20.308)

Fill in all required blanks for everyone who lives with you, either permanently or temporarily. You must list yourself first, then your spouse and children, then other adults and children. Place an asterisk (*) to the left of each person not included in payment.

Members of Household (Last, First, Middle)

Date of Birth

Sex (M/F)

Relation to Head of Household

Marital Status (Married, Single, Widowed, Divorced, Common Law, Separated)

Highest Grade/ Degree Completed

Social Security Number

Verified

Tribal Enrollment Number

Verified

Month

Day

Year

1.

SELF

2.

3.

4.

5.

6.

7.

8.

Section II: TYPES OF FINANCIAL ASSISTANCE AND SOCIAL SERVICES (Check type of Assistance or Services applying for) [Items with an asterisk (*) require BIA Line Officer Approval & Signature; Cost-Sharing for Foster Care or Adoption Subsidy requires BIA Line Officer Approval &Signature]

A.

General Assistance

B. Child Assistance * Foster Care * Residential Care * Adoption Subsidy * Guardianship Subsidy Special Needs * Homemakers Services

C. Adult Care Assistance * Homemakers Services * Residential Care/ Group Home

F. Services-Only Child Protection Adult Protection Child & Family Services IIM Services

D.

Burial Assistance

E.

Emergency Assistance

G.

Information & Referral Only

Section III. EARNED INCOME & UNEARNED INCOME (25 CFR §20.308-§20.310)

Is anyone in the household currently working or have they worked in the past 30 days Yes No If yes, identify Household Member(s) who are working and their earnings: Household Member # 1 _____________________________________ Amount $: _____________ Household Member # 2 _____________________________________ Amount $: _____________ Household Member # 3 _____________________________________ Amount $: _____________

Do you expect to receive or are receiving any of the following listed below: Yes No (If yes, put a check mark in the box in front of all unearned income (not from employment) received by any household members, (see box below; use additional space for further explanation.)

Earned Income

Unearned Income

Wages/ Salary

Amount: $

Supplemental Security Income (SSI)

Amount: $

Alimony/ Child Support

Amount: $

TANF

Amount: $

Gifts/ Contributions

Amount: $

Food Stamps

Amount: $

Income Tax Refund (Federal/State)

Amount: $

Commodities

Insurance Settlement (Auto Accident, etc.)

Amount: $

Foster Care Payments

Amount: $

Interest/ Dividends (Bank Accounts) Other (list):

Amount: $

Other (list) (Example: Carl Perkins P.L. 105-332)

Amount: $

Lease Income (list)

Amount: $

Other (list) (Example: Alaska Native Corporation Dividend

Amount: $

Lottery/ Gaming Income (cash winnings)

Amount: $

Explain the Amount Approved and/or Disapproved- need to specify gross and net earnings. (Social Service Worker Section)

Retirement Benefits/ Pensions

Amount: $

Royalties

Amount: $

Tribal Per Capita Payments

Amount: $

Social Security/ Survivor/ Disability Benefits

Amount: $

Unemployment Benefits

Amount: $

Veteran’s Benefits/ Payments

Amount: $

Worker’s Compensation Benefits

Amount: $

Farm/ Ranch Income

Amount: $

Have you applied for TANF? YES NO Date: __________________

Have you been terminated from TANF past 90 days? YES NO

Are you eligible to reapply for TANF? YES NO

Have you applied for other Resources/ Programs? YES NO Date: __________________

Section IV. STATEMENT OF COOPERATION

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.

Under 18 U.S.C. §1001, the Federal Law concerning fraud states: “Whoever, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or devise a material fact, or makes or uses any false writing or documents, knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both.”

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 the Privacy Act.

Please check & initial: Read, Understood & Signed the Fraud Statement: ________

Read, Understood & Signed the Paperwork Reduction Act: ______

Read, Understood & Signed Release of Information & Privacy Act/FOIA: _______

_______________ ______________________________________ _______________ ___________________________________

Date Signature of Applicant #1 Date Signature of Applicant #2

_______________ ______________________________________ _______________ ____________________________________

Date Social Services Worker Signature Date BIA Line Officer (If Applicable)

FOR BIA HUMAN SERVICES WORKER USE ONLY- INTERVIEW SECTION (Pages 5-18)
Not applicable
A. GENERAL ASSISTANCE (25 C.F.R. §20.300 – §20.323)
Employable:				Unemployable (25 CFR §20.315) (a) Younger than 16 years-old (b) A full-time student under the age of 19 (c) Student; P.L. 100-297 (d) Medical Exemption (e) Incapacitated Person; not yet receiving SSI (f) A caretaker of a person with a Mental/ Physical impairment (g) Parent with Child under the age of 6 (h) Distance Related _____ Miles ______ Time _____ Mode of Transport						Pending Public Assistance Date Applied: ________________________________ Date Verified by Worker: _______________________
Application for Assistance:					Eligibility Factors:
Yes	No	N/A			Yes		No	N/A
		---	Written & Signed Application for Assistance					---	Member of a Federally Recognized Indian Tribe or Alaska Native Village
		---	Timely Approval Notice Provided					---	Reside in a Designated Service Area or Alaska Native Village
		---	Timely Denial Notice Provided					---	Does not have Sufficient Resources
		---	Hearing Rights Provided					---	Concurrent Application to other Agencies
		---	Fraud Statement Provided						ISP Developed and Signed
									Assess Applicant Employability
								---	Not Receiving Public Assistance (SSI/ TANF)
Eligibility Re-Determination:
Yes	No	N/A			Yes		No	N/A
			Change in Status						Monthly Job Search Documented
		---	Review & Update Eligibility (3 or 6 months)						Suspension/ Termination (if applicable)
			- Signed ISP/Progress update every 3 months						Job Search Exemption documented
			- Recipient complying with ISP						Monitor Recipients training or work related activities
		---	Home Visit to verify Income, HH Composition & Residency
Referral(s) to other Resources Services: Check programs to which the applicant is being referred:
Temporary Assistance for Needy Families (TANF) Indian Health Services (IHS) Educational/ GED/ Vocational Mental Health Services Alcohol and Substance Abuse (ASA) Medicare Medicaid Employment Program						Tribal Programs: Identify: ________________________________________________ Social Security Administration (SSA) Housing Programs (HUD) State/ County Programs Veteran’s Administration (VA) Other: Identify: ________________________________________________ No Referral was made

BUDGET CALCULATION (25 CFR §20.311-§20.313):

Household Size: Adults: __________ Children: _________ TOTAL HOUSEHOLD SIZE: __________

1. Monthly State Standard

$ ____________

State Standard:

2. Monthly Deductions

$ ____________

Deductions:

3. Monthly Earned Income

$ ____________

Earned Income:

4. Monthly Unearned Income

$ ____________

Unearned Income:

5. Monthly Liquid Assets* Available

$ ____________

Liquid Assets*:

6. Total Monthly Income

$ ____________

What are your monthly expenses?

7. Total Monthly Countable Income

$ ____________

Shelter/ Rent:

$ _____________

Utilities:

$ _____________

Food:

$ _____________

Clothing:

$ _____________

8. APPROVED AMOUNT

$ ____________

TOTAL MONTHLY EXPENSES:

$ _____________

*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. Additional Comments or Notes

Application Approved Application Disapproved

Date of Approval

Date of Disapproval

Social Services Worker Signature

Date of Signature

Not applicable
B. CHILD ASSISTANCE (25 C.F.R. §20.500 - §20.515)
Name of Child:_______________________________________________ D.O.B. _____________________ Tribe: __________________________________________ Amount of Assistance: $ __________________ Expected Length of Placement: _____________________________ Current Placement Address: _______________________________________________________________ Current Placement Telephone: _________________________________ Reason for Placement (Check all that apply): Abandonment Parents with ASA Problems Neglect Physical Abuse Sexual Abuse Other: ____________________________________________ Outcome of Services: Permanency Plans (developed within 12-months):					TYPE OF ASSISTANCE Foster Care Residential Care Homemaker Adoption Subsidy Guardianship Subsidy Service-Only Title IV-E SSI Independent Living Other Assistance (e.g. Special Needs)
Name of Parents or Guardians:
Mother: _________________________________________________ Whereabouts: __________________________________________ Address (if known): ___________________________________ Income: ________________________________________________ Income Verification Provided (Pay Stub, Written Statement, etc.)				Father: __________________________________________________ Whereabouts: ___________________________________________ Address (if known): _____________________________________ Income: __________________________________________________ Income Verification Provided (Pay Stub, Written Statement, etc.)
Application for Assistance:
Yes	No	N/A
		---	Written & Signed Application for Assistance (Parents or Legal Guardian Must Sign Application)
		---	Timely Approval Notice Provided
		---	Timely Denial Notice Provided
		---	Hearing Rights Provided
		---	Fraud Statement Provided
			NOTE: Bureau Line Office Must Approve/Disapprove Applications for Homemaker Services, Adoption & Guardianship Subsidy, and Cost Share Placement
Eligibility Factors:
Yes	No	N/A
		---	Enrolled Member of a Federally Recognized Indian Tribe or Alaskan Native Village
		---	Reside in Designated Service Area or Alaska Native Village
			Not eligible for Other Federal/State/Tribal Assistance
			Parents Statement that they are unable to provide Care/Supervision
			Family/ Social Service Assessment Supports Parent’s Inability; complete assessment in 30 days; update in 60 days/ 6 months

			Child’s Income is Used to off-set Cost of Care
			Placement Beyond 30-days is supported by a Court Order
			Parents with Income Contributed Toward the Cost of Care
Conditions of Payment
Using Child Assistance: Not applicable
Yes	No	N/A
		---	Payment is Based on State Established Rate for Room & Board Only
			Placement Includes Agreement with Other Agencies Regarding Cost & Service(s): (25 C.F.R. §20.502(b))
			a) Education
			b) Mental Health
			c) Alcohol & Substance Abuse
		---	Payment was NOT Made to a Psychiatric Facility
		---	Payment was NOT Made to an Alcohol and Substance Abuse Treatment Center
		---	Parental Agreement for Payment is in the Case Plan and Followed: Case Plan was Developed, Signed & Implemented
		---	Special Need Cost is Justified
		---	Approved Payment is Less than the Child’s Non-Federal Exempted Income
		---	The Provider Possesses a Current Tribal Certification/ Licensure or are State Licensed
			Effort was Made to Secure Child Support
		---	Monthly Visitation of Social Worker to Child in Placement
		---	The results of the Background Check are in the File (P.L. 101-630 & Adam Walsh Act)
		---	Terms of Payment/ Monthly Invoices show the Daily Rate, Amount Deducted & Amount Paid
		---	Supervisor reviewed Case Plan every 90-Days
For Adoption & Guardianship Subsidy (25 C.F.R. §20.503):
Yes	No	N/A
		---	Long-Term BIA/Tribal Social Services Foster Care Child
		---	Child is Seventeen (17) years of Age or Younger
		---	Child is not Eligible for Other State/Federal Resource, e.g. TANF, IV-E (Denial Letter on File)
		---	Payment does not Exceed State Rate (less Child’s Non-Exempted Income)
		---	Provider is Tribally Certified or Licensed, or State Licensed and has a Home-Study
		---	Payment Subsidy Approved Annually by a Bureau Line Officer (Superintendent)
		---	Child has been in Foster Care prior to Approval to the Subsidy
To a Residential Care Facility:
Yes	No	N/A
		---	Annual Evaluation of the Use of the Facility was Completed
		---	Provide Quarterly Progress Reports- (Best Practice)
		---	Service Follows Signed Case Plans for Child and their Family
		---	Monthly Visitation to Child in Placement
		---	Efforts to Preserve or Reunite the Family is Documented
		---	The Facility is Licensed by the Appropriate Agency
		---	The Payment DOES NOT exceed County/ State Established Rates for Room & Board
For Homemaker (25 C.F.R. §20.504):
Yes	No	N/A
		---	Service DID NOT Exceed 3 months; and IS NOT a 24 Hour Service
		---	Family Assessment Supports Need for Homemaker Service
		---	Number of Hours is Documented; and Payment is According to State Rate
		---	Focus of Service is on Training Others/ Non-Medical Supportive Service
		---	Documented Service Follows Signed Case Plans for Child and the Family
		---	Child & Family is Served Concurrently

For Foster Care:
Yes	No	N/A
		---	Foster Parent Received Training
		---	Annual Evaluation of Home was Completed
		---	Efforts to Preserve or Reunite the Family is Documented
		---	Family Assessment Completed Within 30 Days of Placement; Updated Within 60 days
		---	Monthly Visit to Monitor Progress of Child and Family
		---	The Foster Home is Licensed or Certified
		---	Payment is According to the County/ State Established Rate
Family & Child was Referred to Appropriate Agency For:
Yes	No	N/A		Yes	No	N/A
			Mental Health Services				Therapy
			Alcohol & Substance Abuse				Juvenile Services
			Education Service				Other:
Parental Consent was Obtained for:
Yes	No	N/A
		---	Emergency Transportation
		---	Medical Care
		---	School Attendance
The Record Contains Copies of: (25 C.F.R. §20.506(a-l)):
Yes	No	N/A
		---	(a) Tribal Enrollment Verification
		---	(b) Written Case Plan
		---	(c) Information on Child’s Health Status and School Records (e.g., immunization records and medications)
		---	(d) Parent Consent for Emergency Medical Care, School and Transportation
		---	(e) A Signed Plan for Payment
		---	(f) Copy of the Certification/ Licensure of the Foster Home
		---	(g) Current Photo of the Child
		---	(h) Copy of the Social Security Card, Birth Certificate, Medicaid Card and Current Court Order
		---	(i) Discuss Child’s Needs with Parent’s/ Foster Parent’s / Residential Care & Placement Agency
		---	(k) Document Monthly Visits & Progress
		---	(l) All prior Placement(s) are Listed
Court Responsibilities:
Yes	No	N/A
			Court Reviews Cases Every 6 months
			Court has Permanency Hearings Every 12 Months
		---	Court Orders are NOT prescriptive (25 C.F.R. §20.510)
Payment: Amount of Parent Contributions $ ________________ How often are payments allocated? ______________ Amount of Child Assistance $ ________________ How often are payments allocated? ______________ Name of Payee (Institution): ___________________________________________________________________________
Application Approved Application Disapproved __________________ __________________ Date of Approval Date of Disapproval _________________________________________ _____________________ Social Services Worker Signature Date of Signature

Not applicable
C. ADULT CARE/ HOMEMAKER ASSISTANCE (25 C.F.R. §20.322)/ (25 C.F.R. §20.100)
Name of Applicant/ Recipient: _______________________________________________________________________ Address: _______________________________________________________________________ Tribe: ________________________________________________ Enrollment #: ____________________________________________ Source of Income: ______________________________________ Amount of Income: $__________________
BIA Approved Amount of AC: $ ______ Daily Rate: $ _______ Hourly Rate $ _______ Monthly Rate: $ _______
Name of Legal Guardian: ____________________________________________________________________ Address of Legal Guardian: ______________________________________________ Telephone #: ____________________________ Name of Caretakers: ________________________________________________________________________ Address of Caretakers: __________________________________________________ Telephone #: ____________________________ Outcome of Services:
Application for Assistance:
Yes	No	N/A
		---	Written & Signed Application for Assistance
		---	Timely Approval Notice Provided & Issued by BIA Line Officer
		---	Timely Denial Notice Provided & Issued by BIA Line Officer
		---	Hearing Rights Provided Issued by BIA Line Officer
		---	Fraud Statement Provided Issued by BIA Line Officer
Eligibility Factors:
Yes	No	N/A
		---	Enrolled Member of a Federally Recognized Indian Tribe or Alaska Native Village
		---	Reside in Designated Service Area or Alaska Native Village
		---	Not Eligible for Other Federal/State/Tribal Assistance (Proof is Denial Letter)
		---	Does NOT Need Intermediate or Skilled Care (Supported by Medical Evidence)
		---	Relatives Living in the Home are NOT Available to Care for Applicant
		---	Income not Exempted by Federal Statute is Considered Available
		---	Social Services Assessment Determined Need for Personal Care or Homemaker Services
		---	Purchase of Service Agreement is Approved by BIA Line Officer
		---	Unable to Meet Own Needs
		---	Homemaker is Based on Caseworker Plan for Only a Portion of Any day
Eligibility Re-Determination:
Yes	No	N/A
		---	Review on Going Need Every 6 Months by Social Services & BIA Line Officer
		---	Review Income & Availability of Other Resources Every 6 months by Social Services & BIA Line Officer
		---	BIA Line Officer Reviews Purchase of Service Agreement Every 6 Months

Providers:
Yes	No	N/A
		---	Provider has Federal Background Clearance (Applicable to Homemaker Provider)
		---	Is Licensed or Certified
		---	All Service(s) Provided is Documented
		---	Purchase of Service Agreements is in the File and Followed
		---	Payment is Based on State Rate for Similar Care
		---	Medical Needs are NOT provided
		---	Provide Six Month Progress Report to Bureau/ Tribal Social Services and a Copy to the BIA Line Officer
Additional Comments/ Notes Application Approved Application Disapproved __________________ __________________ Date of Approval Date of Disapproval _________________________________________ _____________________ Social Services Worker Signature Date of Signature

Not applicable
D. BURIAL ASSISTANCE (25 C.F.R. §20.324 - §20.20.326)
Name of Deceased: ________________________________________ Former Address: ______________________________________ Name of Applicant:_________________________________________ Relation to Deceased: __________________________________ Date of Birth: ______________________________________ Date of Death: _____________________________________ Tribe: _________________________________________ Tribal Enrollment #: __________________________ Agency: ______________________________
Application for Assistance:
Yes		No	N/A
			---	Written & Signed Application for Assistance Made Within 30 Days Following Death Date of Application: ______________________________________
			---	Timely Approval Notice Provided
			---	Timely Denial Notice Provided
			---	Hearing Rights Provided
			---	Fraud Statement Provided
Eligibility Factors:
Yes		No	N/A
			---	Enrolled Member of a Federally Recognized Indian Tribe or Alaska Native Village
			---	Deceased Resided in Designated Service Area or Alaska Native Village
			---	Is Determined to be Indigent (All Available Income Including IIM is Considered Available)
			---	NOT Eligible for Other Assistance, Including Tribal Assistance
			---	Verification of Death (e.g., Death Certificate, Newspaper Obituary, Prayer Card, Verification from Mortuary)
Payments:
Yes		No	N/A
			---	Does not Exceed the BIA Burial Rate
			---	Payment Made Directly to Funeral Home/ Third Party Vendor
			---	Extra Transportation Costs are Justified for the Deceased Individual who lived in the Service Area Within the Last Six (6) Consecutive Months
	Additional Comments or Notes
	Application Approved Application Disapproved __________________ __________________ Date of Approval Date of Disapproval _________________________________________ _____________________ Social Services Worker Signature Date of Signature

Not applicable
E. Emergency Assistance (25 C.F.R. §20.329 - §20.330)
Name of Applicant/Recipient: _____________________________________________________________________________________ Tribe: _______________________________________ Tribal Enrollment #: __________________________ Agency: ________________________________ Nature of Emergency: Amount of Assistance: $ ____________________________
Application for Assistance:
Yes	No	N/A
		---	Household Application – Dated & Signed
		---	Timely Approval Notice Provided
		---	Timely Denial Notice Provided
		---	Hearing Rights Provided
		---	Fraud Statement Provided
Eligibility Factors:
Yes	No	N/A
		---	Enrolled Member of a Federally Recognized Indian Tribe or Alaska Native Village
		---	Reside in Designated Service Area or Alaska Native Village
		---	Does not Have Insurance
		---	Application to Other Resource (e.g., Red Cross)
		---	Proof of Loss (e.g., Police Report, Fire Report)
		---	Verification of Income
Payments:
Yes	No	N/A
		---	Household Payment Does Not Exceed Current BIA Rate for Essential & Non-Medical Need
		---	Authorized Payment is Based on Itemized Loss- Loss related to Essential Needs
Additional Comments or Notes
Application Approved Application Disapproved __________________ __________________ Date of Approval Date of Disapproval _________________________________________ _____________________ Social Services Worker Signature Date of Signature

Not applicable
F. Service Only (25 C.F.R. §20.400-20.404)
Application for Assistance:
Yes	No	N/A
		---	Written & Signed Application for Assistance
		---	Timely Approval Notice Provided
		---	Timely Denial Notice Provided
		---	Hearing Rights Provided
		---	Fraud Statement Provided
Eligibility Factors:
Yes No N/A Enrolled member of a Federally Recognized Indian Tribe Reside in Designated Service Area or Alaska Native Village Request is for: Child Protection Adult Protection IIM Services Court Related Service Money Management Counseling (Referral) Other Services (list):
Required Documentation:
Yes No N/A Complete Initial Social Service Assessment Develop/Sign/Implement Case Plan Referred to Other Resource(s) for Assistance/Service When Applicable, Coordinated with the Following Program(s): Tribal Court Law Enforcement – FBI, BIA, US Attorney Other Agencies (State, County, Etc.): Child Protection Team: Multi-Disciplinary Team: Others:
Protective Services Adult Protection Child Protection [Check one]
Yes No N/A Date Referral/Report of Harm Received: ______________________ Date Assessment Conducted: ____________________ Date of Referral Out to (Check one below, fill in date to the right): _____________________ BIA Law Enforcement State CPS Office Other: _____________________________
Date Substantiated: _______________ or Date Unsubstantiated: _______________
Results of Referral Stated Goal/Outcome of Strategies Relative Placement Home Study Conducted
Tribal Court Documentation Shows the Following:
Yes No N/A Initial Court Action; When Applicable (Within 30 Days) 6 Month Review for Child Protection Cases 12 Month Permanency Plan Hearing for Child Protection
Clients Met the Following Mandates:
Yes No N/A Develop, Sign, and Implement Case Plan Follow Agreed Upon Case Plan Cooperated with All Assessment(s)
IIM Services Adult IIM Account Minor IIM Account
Required Documentation: Kennerly Letter is on File (Adult Account Only) Photo Identification Account holder’s address and residence is documented in case record Valid Court Order: (Check One) Custody Order Guardianship Power of Attorney Non Compos Mentis Emancipated Minor Other Information in Evaluation supports Distribution Plan TFAS Account Summary in accordance with Approved Distribution Plan Receipts Collected Case Narrative Reflects current Case Activity 6-Month Review Documented Tribal Resolution on file (if applicable) Account Holder listed on Stratavision Report

Additional Comments or Notes

Application Approved Application Disapproved

__________________ __________________

Date of Approval Date of Disapproval

_________________________________________ _____________________

Social Services Worker Signature Date of Signature

Not applicable
G. INFORMATION & REFERRAL ONLY
DATE	NARRATIVE

OMB Control No. 1076-0017

Expires: xx/xx/20xx

NOTIFICATION TO CLIENT

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 for the Bureau of Indian Affairs (BIA) Child Welfare, Burial and Disaster Assistance Programs. Additional disclosures of this 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 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, Financial Assistance and Social Services – Case Management System, Interior/BIA-8 (76 FR 56787), which can be obtained upon request from the Chief, Division of Human Service, 1849 C Street, N.W., MS-4513-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 records 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.

Under the Privacy Act, BIA may not give out information you give the social service worker except that BIA may share the information with other Federal, State, and Tribal offices and programs who have some responsibility with the social services for which you are applying. The information can also be given to those agencies when you ask them for a job or some other benefit and for law enforcement purposes. This can be done without your consent. For any other person or program wanting information from your case file, you must first give your written consent. You have the right to know what information is in your case record and you can ask to see it. If you believe some information in your case file is inaccurate, ask your caseworker about how to change the information in the case record.

FEDERAL LAW GOVERNING FRAUD

Whoever, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or devise a material fact, or makes or uses any false writing or documents, knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both.

PAPER WORK REDUCTION ACT STATEMENT

This 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 benefits under 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 30 minutes per response, including the time for reviewing instructions, gathering and maintaining data, completing the form. Direct comment regarding the burden estimate or any other aspect of this form to: Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action – Indian Affairs, 1849 C Street, N.W., MS-3071-MIB, Washington, D.C. 20240.

DECISION

When you file an application for social services, you have a right to a written decision within 30 days. In some cases, it may take 45 days. If you disagree with the decision, you may have a review of the decision by seeing your Human Services worker or supervisor. You also may file an appeal and have a hearing. An applicant or recipient must pursue the appeal process applicable to the Public Law 93-638 contract, Public Law 102-477 grant, or Public Law 103-413 Self-Governance Annual Funding Agreement. The regulations for Human Services are in Title 25, Code of Federal Regulations, Part 20.

The amount of grant assistance you may receive or authorize to be expended is based on State Standards of Public Assistance and/or the rates established by the Assistant Secretary - Indian Affairs, minus your income and available resources. The information you give must be accurate. If your circumstances change, you must report this immediately to your Human Services office. By doing so, your Social Services worker can give you proper assistance you are eligible to receive.

Within the limits of its authority, the Human Services Office wants to help you. Ask your Human Services worker to more fully explain any of this information. If you give inaccurate information and receive assistance to which you are not entitled, you will be required to pay it back.

ELIGIBILITY

INDIAN BLOOD (25 CFR §20.100)

Applicant must (1) be a member of a federally recognized Indian Tribe, or (2) in the Alaska service area only, any person who meets the definition of “Native” as defined under 43 U.S.C. 1602(b): “a citizen of the United States and one-fourth degree or more Alaska Indian.” It includes, in the absence of proof a minimum blood quantum, any citizen of the United States who is regarded as an Alaska Native by the Native village or Native group of which he claims to be a member and whose father or mother is (or, if deceased, was) regarded as native by a village or group.

RESIDENCY (25 CFR §20.100 & §20.300)

To be eligible for assistance or services, an applicant must reside in a designated service area.

ELIGIBILITY FOR OTHER SERVICES

Applicant must not be receiving or eligible to receive County/State Public Welfare or Social Security Income. An individual or family who is presumed to be eligible for these programs may, after providing evidence of having applied for those benefits, be granted General Assistance (GA), pending approval of such application. Also, all clients applying for GA who are eligible for assistance from other programs such as Social Security, Unemployment Benefits, Worker’s Compensation, Veteran Benefits, Retirement, etc., will be required to seek and show that they have applied for that assistance. The BIA Financial Assistance and Social Services programs are a secondary resource and cannot be used to supplant or supplement other programs.

POLICY ON EMPLOYMENT: ACCEPTANCE OF AVAILABLE EMPLOYMENT (25 CFR §20.314)

An applicant must actively seek employment including the use of available state, tribal, county, local or Bureau-funded employment services, which they are able and qualified to perform. This means that a recipient, prior to and after applying for GA, must continue to actively seek employment. An applicant or recipient of GA who is determined employable must also accept local and seasonable employment when it is available. According to 25 CFR §20.316, the recipient must demonstrate that they are actively seeking employment by providing the Human Services worker with evidence of job search activities as required in the Individual Service Plan (ISP) and if they do not seek available local and seasonal employment or quit a job without good cause, they cannot receive GA for a period of at least 60 days but not more than 90 after they refuse or quit a job.

Applicants must report all current and expected employment and income. Those claiming temporary or permanent disability are required to present documented medical verification of such disability.

REPORTING REQUIREMENTS

It is the responsibility of all Financial Assistance applicants to report and present appropriate documentary verification of any and all changes that may occur in their income or living arrangements. Failure to do so may constitute fraud and be subject to prosecution and/or repayment of disbursements. Each of the following must be reported as they occur:

• A move from one residence to another

• Addition to or reduction in household members

• Payments received from boarders or lodgers

• Changes or adjustments in housing or Utility Costs

• A move from the Reservation Area, Designated Service Area, or Alaska Native Village

IMPORTANT: Once you have finished reading the Notification to the Client you must sign and date Page 4 of the Application and check that you have read and understand all provisions of the Privacy Act/FOIA, the Fraud Statement, the Paperwork Reduction Act, and sign the Release of Information Statement.

United States Department of the Interior

BUREAU OF INDIAN AFFAIRS

R ELEASE OF INFORMATION

You grant and authorize the exchange of information between the BIA/ Tribal Human Services Program and the following agencies/programs:

Tribal/State Employment Offices Tribal/State Alcohol & Drug Programs

Tribal/State Social Services Programs Tribal/State Housing Programs

Social Security Administration Veteran’s Administration

Tribal/State Education Programs Tribal/State Federal Probation Programs

Tribal/State/Federal Courts Tribal/State Child Protection Services

Tribal/State Medical Services Tribal/State Mental Health Services

Tribal Enterprises Tribal/State Voc-Rehab Programs

Alaska Native Corporations Indian Health Services

State/County Fiduciary Trust Offices

Other (specify): _______________________________ Other (specify): _______________________________

Any information exchanged will pertain to your eligibility to receive Financial Assistance and Social Service benefits or referral to other programs that would benefit you. By signing on the statement of cooperation (Page 3 of the Application) you agree and understand any information obtained will be kept confidential and will be used only for the purposes directly connected with providing benefits or services on your behalf. You further agree and understand that any information obtained may be released to proper governmental agency, court, or law enforcement agencies for purposes of legal and investigative action concerning fraud.

This Release of Information will remain in effect for one (1) year from date of signature or until you request to rescind authorization.

I authorize the Social Services Program to obtain and/or exchange information necessary to establish eligibility for Financial Assistance and Social Services.

________________________________________ _______________ __________________________________________

Name of Applicant (Print) Date Signature of Applicant

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