Application for 477 Services

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1 An Indian Rerganizatin Act Village Under Act f Cngress June 15 th, Chilkat Ave. Klukwan, Alaska HC60 Bx 2207 Haines, Alaska Phne: Fax: Applicatin fr 477 Services What kind f assistance are yu requesting? (CHECK ALL THAT APPY) Child Care Jb Placement and Training General Assistance Adult Higher Educatin Name f Client: Date f applicatin: Phne # Address: **********FOR OFFICE USE ONLY********** Date Applicatin Received: Applicatin Received By: DECISION OF APPLICATION: Apprved Denied Date: / / (Review Dates: / / / / / / ) 1-Mnth Review 3-Mnth Review 6-mnth Review COMMENTS/NOTES: 477 Casewrker Signature: Date: / /

2 Applicatin Instructins: 1. Fill ut the 477 applicatin. 2. Cmplete the additinal applicatin fr the service(s) yu are requesting. 3. Fill in all blanks in the applicatin. If a blank des nt apply t yu, please write NA. 4. The fllwing dcuments must be submitted with yur applicatin. Yur applicatin will be cnsidered incmplete withut these dcuments and will nt be prcessed: Tribal enrllment card r Certificate f Indian Bld fr everyne in yur husehld. Birth Certificate f child (Child Care Assistance nly) Cpy f Driver s License r ther State r Federal identificatin. Cpy f Scial Security card r Scial Security number. 5. Make sure yu sign and date yur applicatin. Eligibility Requirements fr Chilkat Indian Village services: In rder t be eligible, yu must: Be an enrlled member f a federally recgnized tribe and living within ur service area. (Higher Educatin Schlarships d nt have a residency requirement but yu must be Chilkat Indian Village enrlled member). Submit a cpy f yur BIA Certificate f Indian Bld (CIB) r Chilkat Indian Village Tribal enrllment card verifying Indian Bld Quantum. All males 18 t 25 must prvide prf f enrllment with Selective Service. Meet all eligibility requirements fr the prgram(s) t which yu are applying. Must be unemplyed r underemplyed and ecnmically disadvantaged. (Higher Educatin Schlarships d nt have a ecnmical requirement.) Demnstrate ability t btain emplyment based upn training request. (Higher Educatin Schlarships and Child Care des nt apply.) Please nte: Incmplete applicatins cannt be prcessed until all infrmatin and dcumentatin required t cmplete the applicatin has been received by Chilkat Indian Village. Wh d I cntact if I have any questins, need mre infrmatin, and/r need assistance in cmpleting my applicatin? Fr emplyment services, schlarships, general assistance and child care assistance: Please call the 477 Case Manager: (907)

3 APPLICANT INFORMATION/PERSONEL DATA Name (First, Middle, Last) Male/Female Sex Date f Birth Hme Address (Physical Lcatin) City State/Zip cde Mailing Address City State/Zip cde Hme Phne Cell Phne Message Phne Emergency Cntact/ Relatinship Phne number f emergency cntact Persnal Address Marital Status Single Single living with significant ther Married Separated Divrced Are yu enrlled with the Chilkat Indian Village Yes / N Family Status Parent in ne-parent family Parent in tw-parent family Number f dependents under 18 in husehld Ttal Number in husehld Tribal Enrllment Number Have yu applied fr Chilkat Indian Village Services befre? Yes N Other Scial Security Number D yu have a misdemeanr r a felny recrd? Y / N If yes please explain: If yu are a male between the ages f 18 t 25, have yu signed up fr selective services? Y / N NA Have yu received ATAP r TANF in the last mnth: Yes N If yes, hw much: $ Have yu been determined ineligible fr ATAP/TANF: Yes N Reasn: Are yu eligible t reapply fr ATAP/TANF: Yes N Date able t reapply: / / Sign Here X Date

4 Family Incme and Available Funds List ALL surces f incme that yu r yur family members will receive during the next 30 days and current available funds. Yu must prvide verificatin f incme frm yur emplyer. SOURCE OF INCOME & RESOURCES AMOUNT Salary #1: Applicant s Incme/Salary $ NAME OF HOUSEHOLD MEMBER Salary #2: Spuse s Incme/Salary $ Tips r Gratuities $ ATAP TANF-ASAP (State assistance) $ Child Supprt and Alimny $ Fster Care Payments $ Adult Public Assistance (APA) $ Scial Security (SSA) $ Supplemental Security Incme (SSI) $ Disability Insurance $ Cashuts f Retirement r Pensin Plans $ Fd Stamps $ Checking Accunt $ Savings Accunt $ Native Dividends $ Other $ Other $ Anticipated ttal incme $

5 An Indian Rerganizatin Act Village Under Act f Cngress June 15 th, Chilkat Ave. Klukwan, Alaska HC60 Bx 2207 Haines, Alaska Phne: Fax: CERTIFICATION AND AGREEMENT I (we) certify t the best f my knwledge that the infrmatin and dcumentatin cntained in this applicatin is accurate and true. I (we) als understand that additinal infrmatin may be requested t verify what has been submitted. I (we) understand that my applicatin is subject t verificatin, and that falsificatin f infrmatin shall be grunds fr immediate terminatin frm the prgram and will subject me t Federal prsecutin under 18 U.S.C. 1001, which carries a fine f nt mre than $10,000 r federal imprisnment fr nt mre than years, r bth. I (we) als understand that is I (we) receive services as a result f falsified infrmatin, I (we) will have t repay the Tribe fr thse services. I (we) understand and will cmply with Gals and Activities utlined in the family Self-Sufficiency Plan develped with my (ur) Prgram Case Wrker. I (we) understand that there is an Appeal Prcedure by which I (we) can challenge a decisin with regard t this applicatin. I (we) certify that I (we) have received a cpy f this Appeal Prcedure, have read it, understand it and will abide by it. Applicant Signature Date Applicant Signature Date Printed name f applicant Print name f applicant Parent/Guardian Signature Date

6

7 An Indian Rerganizatin Act Village Under Act f Cngress June 15 th, Chilkat Ave. Klukwan, Alaska HC60 Bx 2207 Haines, Alaska Phne: Fax: AUTHORIZATION FOR RELEASE OF INFORMATION I authrize the release f infrmatin requested by the Chilkat Indian Village r its tribal service staff. The requested infrmatin will nly be used in the administratin f the 477 prgram, and will nt be released t any ther persn r agency utside f the Chilkat Indian Village ffice r its tribal service staff. This release f infrmatin will be in effect while I am an applicant r recipient f the 477 prgram, and fr any later investigatins f my eligibility and receipt f benefits. Persns r rganizatins that may be cntacted include, but are nt limited t: the Department f Law, the Department f Public Safety, the Department f Fish and Game, the Department f Labr, the Department f Military & Veterans Affairs, the Department f Revenue, the Bureau f Citizenship and Immigratin Services, Alaska Husing Finance Crpratin, Scial Security Administratin, lcal gvernments, public assistance prgram cntractrs and grantees, tax assessrs, financial institutins, Native crpratins, stck brkerage firms, landlrds, emplyers, schl authrities, and private individuals. A COPY OF THIS RELEASE IS AS VALID AS THE ORIGINAL Printed Name Signature Address Scial Security Number Phne Number Date

8 Appeal Rights All applicants f the prgram have the right t make a written request t appeal all decisins and actins being made n their 477 self sufficiency prgram services. Each time a client makes a written request fr recnsideratin in filing an appeal, the request must cntain the fllwing: 1. The reasn fr the dispute and why the client disagrees with the decisin, actin r findings f the staff that made the decisin/actin. 2. The issue invlved in the dispute. All written request must be made within twenty (20) wrking days frm the date the letter f ntificatin was written. The request fr a frmal appeal must be submitted t Tribal Administratr, Chilkat Indian Village, HC , Haines, AK, r it can be hand delivered t the Tribal Administratr. If yu d nt request within the twenty (20) days, the decisin will becme final and nt subject t appeal under 25 CFR Part 20. If yu are dissatisfied with the Tribal Administratr s written decisin after the frmal hearing then yu may submit yur request fr anther frmal appeal hearing within twenty (20) days f the tribal frmal hearing s written decisin. This request shuld be directed t the Bureau f Indian Affairs, Reginal Office f Human Services, P.O. Bx 25520, Juneau, Alaska, Yu may have representatin, at yur wn expense fr either f the frmal hearings.

9 Chilkat Indian Village CHILD CARE ASSISTANCE Child care assistance is available t lw incme-eligible parents wh reside in the Haines and Klukwan area and wh are emplyed r underging training. The prgram pays a percentage f child care csts incurred when the parent(s) are engaging in emplyment r schl. Parents are urged t apply fr emplyment services and/r higher educatin assistance t enable them t btain reasnable emplyment and self-sufficiency. Children aged 13 and abve are nt eligible fr prgram benefits. The prcess fr calculating funds fr Childcare The parents must prvide prf f incme fr the previus 12 mnths at time f applicatin. The CIV takes the previus twelve mnths incme plus the size f that family and cmpare t a husehld medium incme sliding scale. The sliding scale is an incme range which tells us f hw much parents are respnsible fr and CIV is respnsible fr payments. We will need prf f family incme n a mnthly basis. Parent Applicatin Check List: The applicatin will nt be apprved until these dcuments are received. Incme: Paystubs, Unemplyment stubs, GA/ Public assistance letters, Native Distributins, Bank lans, Persnal lans, Lngevity, PFD, SSI, Tax return and training / wrk schedule. Fully cmpleted applicatin Child and parent identificatin, birth certificates, tribal enrllment and age apprpriate immunizatin recrds Prvider Applicatin Checklist: Licensing, Business License Medical Testing, TB Testing CPR & First Aide, Acquire CPR & First Aide card Backgrund check, Acquire backgrund check frm the Trper/Haines Plice Have medical release frm parents fr medical treatment fr child(ren) The Day Care Prvider respnsibilities All paperwrk must be submitted t the CIV ffice by the 5 th f every mnth fr the previus mnth expenses. Time sheets frm the prvider fr time they cared fr the child r children. The CIV has ten days after receiving all paperwrk in which t determine hw much CIV is respnsible fr and hw much the parent(s) are respnsible fr, befre we distribute payment. I the prvider and parent understand this plicy and will nt expect payment n the same day a time sheet is turned in. I als understand that it is my respnsibility nt the CIV ffice s t reprt my incme t the IRS, when tax time arrives. Signature f Parent Date Signature f Prvider Date List ALL MEMBERS f the Husehld. Enter an asterisk (*) in the bx at left f the name fr each child under the age f 13 included in the Child Care applicatin.

10 Hw many persns live in the huse: Adults Children * NAME RELATION TO HEAD DATE OF BIRTH SEX SOCIAL SECURITY # TRIBE ENROLL # MONTHLY INCOME MEMBERS OF HOUSEHOLD WITH PHYSICAL OR MENTAL HANDICAP NAME NATURE OF PROBLEM TEMPORARY r PERMANENT MINOR r MAJOR VERIFIED

11 Prviders name: Prviders Signature: Prviders Address: Childs Name: Parents Signature: 477 Case Manager Signature: Billing Mnth: Date/Day Time Time Ttal hurs in/time Out in/time Out 1 st P/T F/T H 2 nd P/T F/T H 3 rd P/T F/T H 4 th P/T F/T H 5 th P/T F/T H 6 th P/T F/T H 7 th P/T F/T H 8 th P/T F/T H 9 th P/T F/T H 10 th P/T F/T H 11 th P/T F/T H 12 th P/T F/T H 13 th P/T F/T H 14 th P/T F/T H 15 th P/T F/T H 16 th P/T F/T H 17 th P/T F/T H 18 th P/T F/T H 19 th P/T F/T H 20 th P/T F/T H 21 st P/T F/T H 22 nd P/T F/T H 23 rd P/T F/T H 24 th P/T F/T H 25 th P/T F/T H 26 th P/T F/T H 27 th P/T F/T H 28 th P/T F/T H 29 th P/T F/T H 30 th P/T F/T H 31 st P/T F/T H Ttal P/T (Office use nly) Ttal F/T (Office use nly) Ttal H (Office use nly)

12 CCDF Prvider Rate Sheet Name / Facility Physical Address City Phne Business License # Effective Date Mailing Address State / Zip SSN# Checks payable t Type f facility Center Licensed Grup Hme Hme Licensed Family Hme Attendance rates listed are state rates, Infant 0-18 Mnths Tddle mnths Preschl 37 t 6 years Schl age 7 12 years Mnthly F/T P/T F/T P/T F/T P/T F/T P/T Daily F/T P/T F/T P/T F/T P/T F/T P/T Hurly P/T is 0-5 hurs F/T is 5-10 hurs hurly is 2 hurs r less. I will ntify Tribal Services f any changes a week prir. All charges are shwn abve. Prviders signature Date Tribal Services Signature Date

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