Energy Assistance Application

Energy Assistance Application

Osage Nation Financial Assistance Department
627 Grandview Avenue Pawhuska, OK 74056
Phone: (918) 287-5325
Email: financial-assist@osagenation-nsn.gov
Dear Energy Assistance Applicant:
The Energy Assistance Program operates on a fiscal year (October through September) and serves low-income Native American households within the Osage Reservation (Osage County) by providing residential energy assistance. The program is not an emergency program, you should continue to pay your utility bills. This program provides financial assistance applied to the energy bill and is seasonal. Please read and complete each section of the attached application. Completed applications contain the following attachments:
____ Complete, signed Energy Assistance Application
____ Photo Identification for each adult household member
____ Membership card or CDIB of federally recognized tribe, for each household member
____ Social Security card, for each household member
____ Current Energy bill
____ Verification of household income, for the thirty (30) days prior to the date on this application
If applicable:
____ Verification of homeownership, if requesting HVAC repair or replacement
(General Warranty Deed, Contract for Deed, Manufactured Home Title, BIA permit, Lease to Purchase)

Application Date Application Date / MM / DD YYYY
Name Name First Last
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
County
Federally Recognized Tribe & Membership Number
Social Security Number
Phone Phone - ### - ### ####
Date of Birth Date of Birth / MM / DD YYYY
Ethnicity/Race/Gender Abbreviation Chart

Please fill in the following three questions as shown on this chart. They must match for your form to be processed properly.

Gender:

M = Self Identified Male
F = Self Identified Female
O= Other
U = Unknown/Not Reported

Ethnicity:

HLSO = Hispanic, Latino, or Spanish Origins

NHLSO = Non-Hispanic, Latino, or Spanish Origins

U = Unknown/Not Reported

Race:

AIAN = American Indian or Alaska Native
A = Asian
B = Black or African American
NHOPI = Native Hawaiian or Other Pacific Islander
W = White
M = Multi Race (2 or more of the above)
O = Other/Unknown
Gender
Ethnicity
Race
Household Member Information

Please provide the information of all other household members in the following format:

Jane Doe, Age, Gender, Ethnicity, Race, Social Security Number, Veteran yes/no, Disabled yes/no
Household Member Information
Household Income

(If you do not receive the income source, ENTER 0, do not leave any source blank)
Wages (net)
Self-Employment
Contract
SSA or SSI
Rental Property Income
Alimony
Child Support
Unemployment Benefits
TOTAL (Calculate all of the above)
Household Adults: Please list the adult name and their total monthly net income
Assistance Information

Please answer all questions
Have you received utility assistance from DHS since October 1st?
Do you receive utility allowance?
Do you have a disconnect notice on the utility account?
Is the utility currently disconnected?
Do you rent or own your home?
If answered "Rent" Select the most applicable option.

If answered "Rent" Select the most applicable option. Rent with utilities billed separately Rent with utilities included in rental fee Other Unknown / Not Reported
Which type of utility assistance are you applying for?

Which type of utility assistance are you applying for? Heating Cooling
How do you heat your home?

How do you heat your home? Natural gas electric Wood Propane
how do you cool your home?

how do you cool your home? Central A/C Window Units
Vendor:
Crisis Assistance

Crisis Assistance Utility Cost HVAC Repair/Replacement
If you are requesting crisis assistance please check all that apply:

If you are requesting crisis assistance please check all that apply: Potential health threat to a vulnerable applicant and household Non-working heating or cooling equipment (repair and replacement available to homeowner’s only) Life-threatening crisis constitutes an energy burden that may result or create a medical or health emergency
Documentation

Please provide all of the following requested documentation and information.
Picture of all Photo IDs

Attach Files
Picture of all Social Security Numbers

Attach Files
Picture of all Tribal Membership Cards

Attach Files
Picture of most recent Energy Bill

Attach Files
Picture of Income Verification

Attach Files
Additional Picture of Income Verification

Attach Files
Applicant Rights and Responsibilities

I understand my completed application will be processed within ten (10) business days and I shall receive a denial or approval letter. The approval letter will include benefit amount and vendor information. If the application is denied, I will receive a notification letter stating the reason and information detailing the appeals process. I understand that I have ten (10) business days to appeal.
Federal law governing fraud: “Whoever, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals, or covers up by any trick scheme or device, a material fact, or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing on documents, knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both.”
The information contained within this Agreement and any supporting documentation attached is a protected record under the Osage Nation Open Records Act. The Osage Nation will not disclose any record containing protected information without the written consent of the applicant unless the information is being used to perform the duties of an Osage Nation employee. The applicant’s information may be released to other Osage Nation Departments/Programs with which the applicant is receiving or requesting services and to the Office of the Osage Nation Attorney General for an investigation to detect or eliminate fraud.
The undersigned hereby expressly recognizes that the benefit sought or presently enjoyed by the undersigned from the Osage Nation government, to wit: Osage Nation Energy Assistance is a privilege and a benefit to the undersigned and not a property interest or matter of right. In consideration of, and as a condition precedent to, the grant, issuance or continued enjoyment of this privilege and benefit, regardless of whether the undersigned is a natural or artificial person or entity, and further regardless of whether the undersigned is of Indian or non-Indian blood, descent or legal character, the undersigned hereby stipulates and agrees that jurisdiction over all matters and disputes arising out of exercise of such a benefit and privilege shall vest in the Osage Nation Trial Court. The undersigned further stipulates to be bound by all Osage Nation laws, codes, regulations, policies and procedures governing such benefits, privileges and activities. The undersigned further expressly waives all further rights to contest the jurisdiction of the Osage Nation Trial Court over any such matters, disputes, actions or decisions of any branch of the Osage Nation government.
If you have any information about possible fraud, waste or the misuse of LIHEAP funds, please help us eliminate it by calling Health and Human Services Fraud Alert hotline. 1(800) HHS-TIPS, 1 (800) 477-8477 or Visit the Website: https://forms.oig.hhs.gov/hotlineoperations/nothhsemployeeen.aspx or contact them by Mail: US Department of Health and Human Services, Office of Inspector General, ATTN: OIG HOTLINE OPERATIONS, PO Box 23489, Washington, DC 20026
I. Release of Information
I have read and understand the above statements, and understand the program policy is available for public review on the Osage Nation website. I authorize the Osage Nation Financial Assistance Department to obtain necessary information from other sources to determine my eligibility for assistance. I agree to notify the Osage Nation Financial Assistance Department of any changes in the information provided on this application, and that all information provided is true and correct to the best of my knowledge.
Applicant Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Spouse/Significant Other

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.