Please enable JavaScript in your browser to complete this form.CIFInternal use onlyService Area *Fresno CountyMadera CountyMariposa CountyMonterey CountySan Benito CountySan Luis Obispo CountyName *FirstLastPhone *Section 1Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSection 2Family Type *1-Parent2-ParentRelative HomeOtherTANF Cash Aid *YesNoTotal Number In Household? *Number of Dependents under 18yrs? *List Household Family MembersAdd Household Member?YesHousehold Member 1Member 1 Name *FirstLastMember 1 Tribal Affiliation *Member 1 Gender *FemaleFemaleMaleOtherMember 1 Marital StatusMember 1 Degree or Highest Grade Attended *Member 1 Date of Birth *Member 1 Name of School Attending *Add Household Member 2?YesHousehold Member 2Member 2 Name *FirstLastMember 2 Tribal Affiliation *Member 2 Gender *FemaleMaleOtherMember 2 Marital Status *Member 2 Degree or Highest Grade Attended *Member 2 Date of Birth *Member 2 Name of School Attending *Add Household Member 3?YesHousehold Member 3Member 3 Name *FirstLastMember 3 Tribal Affiliation *Member 3 Gender *FemaleMaleOtherMember 3 Marital Status *Member 3 Degree or Highest Grade Attended *Member 3 Date of Birth *Member 3 Name of School Attending *Add Household Member 4?YesHousehold Member 4Member 4 Name *FirstLastMember 4 Tribal Affiliation *Member 4 Gender *FemaleMaleOtherMember 4 Marital Status *Member 4 Degree or Highest Grade Attended *Member 4 Date of Birth *Member 4 Name of School Attending *Add Household Member 5?YesHousehold Member 5Member 5 Name *FirstLastMember 5 Tribal Affiliation *Member 5 Gender *FemaleMaleOtherMember 5 Marital Status *Member 5 Degree or Highest Grade Attended *Member 5 Date of Birth *Member 5 Name of School Attending *Add Household Member 6?YesHousehold Member 6Member 6 Name *FirstLastMember 6 Tribal Affiliation *Member 6 Gender *FemaleMaleOtherMember 6 Marital Status *Member 6 Degree or Highest Grade Attended *Member 6 Date of Birth *Member 6 Name of School Attending *Section 3At Risk Indicators *Living in high crime rate areaMember of low-income familyAbsent parent (single parent children)Low academic skills (not low intelligence)Parents are not high school graduatesHomelessness /housingLiving with caretaker /relativeSubstance abuse issuesHave negative self-perceptions; low self-esteemPregnant /Parenting teenLiving on or near Rancheria landsDomestic violencePrevious involvement in Juvenile Justice SystemLiving in unstable school districtOther(please check all that apply)OtherPlease explainI certify that all information reported in this application is accurate to the best of my knowledge and hereby authorize the information to be used by North Fork Rancheria Tribal TANF Program, for the purpose of Data Tracking. Disclaimer: I understand that my information is confidential and will not be divulged to anyone without my permission.Signature *Clear SignatureDate *Submit
