Human Services Application

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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.

ENTERPRISE RANCHERIA

2133 Monte Vista Ave.

Oroville, CA 95966

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

HUMAN SERVICES/EMERGENCY ASSISTANCE APPLICATION

Applicant Information

Applicant Name(Required)

Date of Birth(Required)

Spouse

Date of Birth

Mailing Address(Required)

Phone(Required)

Other Household Members

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Request Details

Please Describe Your Emergency / Human Services Request(Required)

Required Documentation

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

Signature

Typed Signature(Required)

Signature Date(Required)

Vendor 1

Vendor 1 Name

Vendor 1 Address

Vendor 1 City, State & Zip

Vendor 1 Amount Due

Vendor 2

Vendor 2 Name

Vendor 2 Address

Vendor 2 City, State & Zip

Vendor 2 Amount Due

Vendor 3

Vendor 3 Name

Vendor 3 Address

Vendor 3 City, State & Zip

Vendor 3 Amount Due

Section Break

Eligibility for Human Services/Emergency Assistance:

Must be an Enrolled Tribal Member 18 years of age or older
Applicant has not used Elders or Disability Assistance for the calendar year (Jan-Dec).
Assistance payment shall not exceed $1,500.00 for the calendar year (Jan-Dec).
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 the 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 the vendor form with the name, address, and amount owed to each vendor.

Download Application

Human Services Application

Applicant Information

Other Household Members

Request Details

Signature

Vendor 1

Vendor 2

Vendor 3

Section Break

Connect With the Tribe

Connect With the Tribe