ASSISTANCE SELECTION
Please mark the assistance you are seeking. Where appropriate, check will be made payable and mailed directly to the vendor.
What is considered income?
Proof of GROSS MONTHLY INCOME (before taxes, within last 30 days’ time period) is required for all Adults (18 years of age or older, not enrolled in High School or GED Program). If you have “no income” submit a Wage Printout. Wage Printouts are available from the Employment Office, at 801 Oak Ave., Klamath Falls, OR - (541) 883-5630.
Proof of income includes: check stubs, award or benefit letters. Bank statements are not valid proof of income, due to the following reasons: (1) Bank statements show net earnings, they do not show gross earnings, and (2) an individual’s source of income may be split in more than one bank account, and therefore a bank statement may not provide accurate total earnings.
I hereby authorize the staff of the Klamath Tribes Administration to exchange information with the following agencies/programs:
I hereby authorize the Klamath Tribes Administration staff or its agents, access to any records in order to verify information given. I also consent to any legally authorized investigation for confirmation of information from any State, Federal or Tribal offices or other agents so that I am eligible for assistance available through the COVID-19 Emergency Assistance. I understand I am not entitled to benefit from the COVID-19 Program.
If I receive assistance as a result of withholding information or by knowingly providing false or fraudulent information, I must repay the assistance and may be found guilty of fraud and fined up to $10,000 or put in prison or both. I understand I may be entitled to a fair hearing if requested within fifteen (15) day of completed date of application or date of denial. I understand that no person may be denied assistance on the basis of race, color, sex, age, religion, national origin or political belief. I agree to all terms of this disclaimer and am allowing the Klamath Tribes Administration access to my personal information to process my Application. By signing this application, I understand that if I am approved, I may be notified at a later date.