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0uscogee (Creek) 1ation

$PP#:__________________

Social SerYices Department

Social SerYices Office

$pplication

SECTIO1 1. HOUSEHOLD I1FOR0$TIO1

$. Head of Household 1ame: ________________________________________________

0aiden 1ame: ___________________

Is the Head of Household Indian"

<es

If \es, please list Tribe/Roll#: ____________________________

0arital Status:

Single

In Relationship

0arried

Separated

DiYorced

:idoZ/er

B. Spouse/Significant Other 1ame (if applicable): ________________________________

0aiden 1ame: ___________________

Is the Spouse/Significant Other Indian"

<es

1o If \es, please list Tribe/Roll#: ____________________________

C. Is the Head of Household non-Indian and appl\ing on behalf of an Indian minor"

<es

0inor 1ame: _____________________________________

DOB: __________________ SS1#: ______________________

Please check if the Head of Household or Spouse/Significant Other is:

Legal Parent

Legal Guardian

Foster Parent

Other:_______________________________________________________________________

D. $re \ou or an\ household member receiYing an\ of the folloZing" (Please check all that appl\.)

Social Securit\ $dministration (SS$)

Supplemental Securit\ Income (SSI)

Social Securit\ Disabilit\ (SSDI)

Retirement Pension

E. $re \ou or an\ household member a 9eteran"

<es

$re \ou receiYing disabilit\"

<es

F. Do \ou or an\ of the household members receiYe S1$P or Commodities"

<es

S1$P $mount ReceiYed __________

EffectiYe Dates: ______________________________________________

Commodities EffectiYe Dates: _______________________________________________

G. Do \ou or an\ household member receiYe Temporar\ $ssistance for 1eed\ Families (T$1F)"

<es HoZ much a month" ____________

H. $re \ou appl\ing for serYices due to a Child :elfare case"

<es

Through Zhich office"

DHS

Tribal

Case :orker 1ame: _____________________________________ Phone 1umber: ______________________________

I. $re \ou in an abusiYe relationship"

<es

0C1 Famil\ 9iolence PreYention Program

$re \ou being stalked"

<es

918-732-7979

HaYe \ou been sexuall\ assaulted"

<es

If \ou ansZered \es, please call to speak Zith an adYocate or ask

the 0C1 Social SerYices staff to assist \ou.

Do \ou feel unsafe in \our home"

<es

J. $re \ou or an\ of \our household members a member of a 0uscogee (Creek) 1ation Indian Communit\ Center or Tribal ToZn"

<es	1o	If \es, Zhich Communit\ Center" __________________________________________________

<es	1o	If \es, Zhich Tribal ToZn"________________________________________________________

Page 1 of 6

Revised 1/2015 ss

SECTIO1 2. CO1T$CT I1FOR0$TIO1

$. $ddress: _______________________________________________________________________________________________

Count\: _________________ Cit\: ____________________________________

Phone: _________________________	0essage Phone: ___________________
Best Za\ to contact (check all that appl\):		Phone Call	Text
Best Za\ to contact (check all that appl\):		Phone Call	Text

State: ____________ Zip: ___________

Email: ____________________________

0ail Letter		Email

		SECTIO1 3. HOUSI1G SITU$TIO1

$.	Renter/$mount __________/month		HomeoZner/0ortgage $mount __________/month

Homeless/Sta\ing Zith famil\ or friends. Please list the person \ou are sta\ing Zith:______________________________

Other: ___________________________________________________________________________________________

___________________________________________________________________________________________

B.:hat utilities do \ou pa\" (necessit\ utilities onl\)

Electric

Gas

:ater

Propane

Other: __________________________________

SECTIO1 4. HOUSEHOLD CO0POSITIO1

				REL$TIO1 TO
				HE$D OF
HOUSEHOLD 0E0BER 1$0E	DOB	SS1#	TRIBE/ROLL#	HOUSEHOLD

10.

SECTIO1 5. I1CO0E 9ERIFIC$TIO1

PLE$SE LIST $LL I1CO0E FOR THE HOUSEHOLD

E$R1ED $1D U1E$R1ED I1CO0E

(Emplo\ment, Unemplo\ment Benefits, Child Support, T$1F, SS$, SSI, SSDI, 9$, Retirement, Ro\alties, etc.)

HOUSEHOLD 0E0BER 1$0E	I1CO0E		HO: OFTE1
HOUSEHOLD 0E0BER 1$0E	(GROSS $0OU1T)		HO: OFTE1
	(GROSS $0OU1T)
1.	D$IL<	:EE.L<	BI-:EE.L<	0O1THL<	SE0I 0O1THL<
2.	D$IL<	:EE.L<	BI-:EE.L<	0O1THL<	SE0I 0O1THL<
3.	D$IL<	:EE.L<	BI-:EE.L<	0O1THL<	SE0I 0O1THL<
4.	D$IL<	:EE.L<	BI-:EE.L<	0O1THL<	SE0I 0O1THL<
5.	D$IL<	:EE.L<	BI-:EE.L<	0O1THL<	SE0I 0O1THL<
6.	D$IL<	:EE.L<	BI-:EE.L<	0O1THL<	SE0I 0O1THL<

**********************************************OFFICE USE O1L<*********************************************

TOT$L GROSS 0O1THL< I1CO0E:	Does applicant haYe the abilit\ to maintain"	<es	1o
TOT$L GROSS 0O1THL< I1CO0E:	Does applicant haYe the abilit\ to maintain"	<es	1o
TOT$L GROSS $11U$L I1CO0E:	$mount ______________
TOT$L GROSS $11U$L I1CO0E:	$mount ______________

Page 2 of 6

Revised 1/2015 ss

SECTIO1 6. E0PLO<0E1T/EDUC$TIO1 ST$TUS

HE$D OF HOUSEHOLD

Emplo\ed

Unemplo\ed

Full-time

Laid Off

Part-time

Terminated

0edical LeaYe

Resigned

1st Emplo\er ____________________________________

Disabled

Start Date ___________________________________

Homemaker

2nd Emplo\er ____________________________________

Last Emplo\er ____________________________

Start Date ___________________________________

Last date Zorked _____________________

1otes: ______________________________________________

Did \ou file for unemplo\ment"

<es

______________________________________________

Decision ____________________________

______________________________________________

_____________________________

______________________________________________

_____________________________

Highest education (please cHECK )

GED

College Degree_____________________

Other:_____________________________________

Other:____________________________________________

$re \ou interested in furthering \our education"

<es

SPOUSE/SIG1IFIC$1T OTHER

Emplo\ed

Unemplo\ed

Full-time

Laid Off

Part-time

Terminated

0edical LeaYe

Resigned

1st Emplo\er ____________________________________

Disabled

Start Date ___________________________________

Homemaker

2nd Emplo\er ____________________________________

Last Emplo\er ____________________________

Start Date ___________________________________

Last date Zorked _____________________

1otes: ______________________________________________

Did \ou file for unemplo\ment"

<es

______________________________________________

Decision ____________________________

______________________________________________

___________________________________

______________________________________________

___________________________________

Highest education (please cHECK )

GED

College Degree_____________________

Other:_____________________________________

Other:____________________________________________

$re \ou interested in furthering \our education"

<es

Page 3 of 6

Revised 1/2015 ss

SECTIO1 7. :H$T IS <OUR SITU$TIO1 $1D THE RE$SO1 <OU $RE REQUESTI1G $SSIST$1CE"

SECTIO1 8. :H$T T<PE OF $SSIST$1CE $RE <OU REQUESTI1G"

Rent and/or deposit pa\ment	HoZ much"	Rent____________ Deposit_______________
0ortgage pa\ment	HoZ much"	Pa\ment____________ Deposit_____________
Electric and/or deposit pa\ment	HoZ much"	Pa\ment____________ Deposit_____________
Electric and/or deposit pa\ment	HoZ much"	Pa\ment____________ Deposit_____________
Gas/Propane/:ood and/ or deposit pa\ment	HoZ much"	Pa\ment____________ Deposit_____________
Gas/Propane/:ood and/ or deposit pa\ment	HoZ much"	Pa\ment____________ Deposit_____________
:ater and/or deposit pa\ment	HoZ much"	Pa\ment____________ Deposit_____________
:ater and/or deposit pa\ment	HoZ much"	Pa\ment____________ Deposit_____________

Other: _______________________________________________________________________________________________

Energ\ $ssistance (Heating: Dec ‒ 0arch /Cooling: June ‒ Sept)

0edical TraYel $ssistance: (please complete beloZ)
Date of $ppointment(s):_______________________			0edical Condition/Problem:____________________
__________________________________________			__________________________________________
__________________________________________			__________________________________________
:here is the doctor/hospital located"____________			__________________________________________
_________________________________________
__________________________________________			:ho Zill be traYeling Zith \ou" _________________
OYernight sta\ required"	<es	1o	___________________________________________

T\pe of Yehicle to be driYen" (<ear, 0ake, 0odel)			___________________________________________
__________________________________________			___________________________________________
__________________________________________

Page 4 of 6

Revised 1/2015 ss

1atural Disaster $ssistance: (please complete beloZ)

Fire	Date: ___________	Comments: ____________________________________________________________
Tornado	Date: ___________	Comments: ____________________________________________________________
Flood	Date: ___________	Comments: ____________________________________________________________
Hurricane	Date: ___________	Comments: ____________________________________________________________
Earthquake	Date: ___________	Comments: ____________________________________________________________
Other	Date: ___________	Comments: ____________________________________________________________
Other	Date: ___________	Comments: ____________________________________________________________

:hat are \our immediate needs" (shelter, food, clothing, etc.)_______________________________________________________

________________________________________________________________________________________________________

SECTIO1 9. DUPLIC$TIO1 OF SER9ICES

My household and I H$9E 1OT received assistance from DQ\VWDWHORFDOFRPPXQLW\IHGHUDORUWULEDORUJDQL]DWLRQwithin the last 12 months.

My household and I haYe received assistance from:
$GE1C<				UTILIT<
Tribal Agency ___________________________________________				Rent/ Mortgage payment or deposit
Tribal Agency ___________________________________________				Rent/ Mortgage payment or deposit

Tribal Town ____________________________________________				Electric bill or deposit
I ndian Community Center__________________________________				Gas, Wood, Propane bill or deposit
Church ________________________________________________				Water bill or deposit
LI HEAP ________________________________________________				Other _________________________________________________
LI HEAP ________________________________________________				Other _________________________________________________
DHS __________________________________________________				Other _________________________________________________
Other _________________________________________________				Other _________________________________________________


Other _________________________________________________				Other _________________________________________________
Other _________________________________________________				Other _________________________________________________
Other _________________________________________________				Other _________________________________________________

**:E 9ERIF< $LL I1FOR0$TIO1 :ITH $LL 9E1DORS. IF <OU H$9E 1OT P$ID <OUR BILL O1 <OUR O:1 I1 THE L$ST 6 0O1THS,

<OU :ILL 1OT BE ELIGIBLE FOR $SSIST$1CE THROUGH THE SOCI$L SER9ICES OFFICE U1LESS <OU P$< $ PORTIO1 <OURSELF**

SECTIO1 10. PUBLIC DISCLOSURE OF POTE1TI$L CO1FLICT OF I1TEREST

Per 24 CFR 1000.30 (b) and (c), applicants appl\ing for Housing/1$H$SD$ program are required to proYide the folloZing:

Are you and/ or any immediate family member an employee of Muscogee (Creek) Nation or any other entity under the Nation?		Yes	No
Name:	Relation:
Name:	Relation:
Name:	Relation:
Name:	Relation:

Page 5 of 6

Revised 1/2015 ss

DISCLOSURE

F$IR HE$RI1GS ST$TE0E1T:

Once the Social Services Office is in receipt of an application, it will be considered pending until all documentation required is received or up to 15 EXVLQHVV days, whichever comes first. After 15 EXVLQHVV days, the application will be denied. All required documentation must be received in

order for eligibility to be determined. I f the applicant feels the decision of the Social Services staff is in error, he/ she may file a written appeal, within EXVLQHVV days from the date on the letter of denial, to the director of the Social Services Department. The Social Services director will forward the appeal letter to the Appeals Team for review and a decision will be made within 10EXVLQHVV days from receiving the appeal letter. All decisions will

be based according to tribal and federal law, and the programs policies and procedures to ensure the integrity of the department.

PRI9$C< $CT ST$TE0E1T:

The MCN Social Services Department cannot give out applicant’s information. However, Social Services can share the information with other Federal, State, Tribal offices, programs and/ or businesses who have some responsibility with the services for which the applicant is applying. For any other person or program wanting information from the applicant’s case file, the applicant must first give his/ her consent by signing the release of information section below.

FR$UD ST$TE0E1T:

All information pertinent to services requested is subject to verification. This includes, but is not limited to, landlords, mortgage companies, utility companies, employer, funeral homes, schools, etc. Falsification of this information shall be grounds for 1) denial of application, 2) not eligible to receive assistance for six (6) months up to a year, 3) all parties, agencies, tribes, etc. will be notified, and 4) may be forwarded to the MCN Attorney General’s Office if further action is needed.

RELE$SE OF I1FOR0$TIO1:

Should you choose a friend or family member to receive or give information to our staff in regards to the application, please list their name, relation, and last f o u r d ig it s of their social security number for identification purposes:

Name:		Relation:	SSN:	XXX-XX-
Name:	Relation:		SSN:	XXX-XX-
Name:	Relation:		SSN:	XXX-XX-

This Release of I nformation will remain in effect for one (1) year from date of signature or until you request to rescind authorization. Should \ou choose a famil\ member or friend to obtain information, \ou must check the box beloZ authorizing it. Should \ou fail to check either box and/or sign, \our application Zill be considered incomplete and Zill be sent back to \ou.

I authorize the Social Services Department to obtain and/ or exchange information with the person(s) listed above.

I do not wish to list any person(s) .

CERTIFIC$TIO1:

By signing below, I certify I have read this application or had this application read to me and that all information provided by me, oral and written, is true and accurate. I also acknowledge I have read and understand the Fair Hearing Statement, Privacy Act Statement, Fraud Statement, and the Release of I nformation Section.

Head of Household Name (printed):

Date:

Head of Household Signature:

**********************************************OFFICE USE O1L<*********************************************

Staff 0ember 1ame:

Date Completed:

$pplication(s) taken:

Page 6 of 6

Revised 1/2015 ss

Question	Answer
Form Name	Creek Nation Application Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	muscogee creek nation social services phone number, creek nation hardship, creek nation clothing application 2018, oklahoma creek nation social services

Creek Nation Application Form – Fill Out and Use This PDF

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