Human Services Application Form

This field is for validation purposes and should be left unchanged.
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Eligibility for Human Services/Emergency Assistance:

1.      Must Be an Enrolled Tribal Member 18 years of age or older

2.      Applicant has not used Elders or Disability Assistance for the calendar year (Jan-Dec).

3.      Assistance payment shall not exceed $1,500.00 for the calendar year (Jan-Dec).

4.      Applicant must be in good standing with the Tribe.


EMERGENCY SCOPE OF ASSISTANCE

Utilities: PG & E, Water, Phone, Etc.

Rent/Mortgage, Property Taxes, Move in assistance, Etc.

Vehicle, vehicle repair, Registration, Etc.- Gas Card yearly max amount $200.00.

Home repairs, appliances, Etc.

Medical, Prescriptions, Glasses, Etc.

Emergency Food - Not to exceed yearly max amount of $400.00 and you must turn in receipts.

And Any other Emergency Requests approved by Program Manager.


Documentation:

For all requested emergency items, we need quotes attached in order to make payment. If the documentation is not attached, we will not be able to process your assistance.

Also, please complete vendor form with Name, Address and amount owed to each vendor.

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ENTERPRISE RANCHERIA

2133 Monte Vista Ave.

Oroville, CA 95966

Phone: (530) 532-9214  Fax: (530) 532-1768


HUMAN SERVICES/EMERGENCY ASSISTANCE APPLICATION

Applicant Information

Other Household Members

Request Details

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 64 MB.

Signature

Vendor 1

Vendor 2

Vendor 3

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