Tolani Lake Veterans Financial Assistance Request Form

Tolani Lake Chapter
Document Check off List
For Veterans Funding
1. Application
2. Evidence of Land Ownership ( Agreement)
Homesite lease or Home ownership certification
3. Material(s) Listing (Quote)
4.
Registered Voter Vertification
5.
DD214
6.
COPY of Social Security Card
7.
COPY of Applicant's Certification of Indian Blood
8.
Acknowledgment
YES
NO
Availability of Funds
Budgeted Item
Committee Approval
REQUESTED BY:
Office Specialist/Accounting
APPROVED BY:
DATE:
_
DATE:
_
Clerk
Chapter Manager
CONCURRED BY:
DATE:
Committee Chairperson
_
·
.
Tolani Lake Chapter
VETERANS APPLICATION
'"All questions in the application must be answered; read instructions before completing
This form; Incomplete applications may result in denial of request; read carefully before
You sign and date your application.
Assistance not to exceed $900.00
A.
Application Information:
t
Name: ________________
2.
Current Address:
3.
DD214:
4.
Martial Status:
B.
Census#
_
Widowed
Single:
_
Assistance Information:
I.
Homesite Lease #
or Home Owner Certification
2.
Type of Assistance requested:
_
___
Renovation of current home
____
Minor Repairs
___
Weatherization
____
Addition to existing house
___
.Stove
____
Handicap Access Renovation
___
Waterline/Sewer/septic Tank
----
___
Miscellaneous Material to complete home
___
Other (explain)
Electrical Materials
3.
Location of the house to be repaired, constructed, or purchased (give precise directions)
4.
Is electricity available?
5.
Sewer System:
City Sewer
6.
Water Source:
City System
7.
Number ofBedrooms:
8.
Bathroom facilities:
Flush Toilet
_____
Yes
Yes
Septic Tank
Chemical Toilet.
Private Well
_
No
No
Tub
1
Community Tank __
Size ofHouse
Yes
other
other
by
No
Lavatory __
_
Yes __
No
-,
'
C.
General Information:
I.
Have you of anyone in your household received tribal housing assistance?
_____
yes
_____
No
If yes, indicate amount received year and location where funds were utilized.
2.
Do you own any other house not occupied by your family?
____
yes
_____
No
If yes, give location
3.
D.
MAP TO LOCATION OF HOME:
APPLICANT'S ACKNOWLEDGEMENT
I certify that all of the answers given herein are true, complete to the best of my knowledge and are
made in good faith.
Applicant's Signature:
Date:
_
This information is being collected to select eligible individuals to participate in the Tolani Lake
Chapter Veteran Fund Program. This information will be used to determine the eligibility of the
applicant; response to this request is required to obtain benefit.
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