TANF Program Application Fields marked with an * are required Personal Information Personal Information First Name * Middle Name * Last Name * Mailing Address * City * State * - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC Zip * Physical Address * City * State * - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC Zip * Email * Confirm Email * Home Phone * Cell Phone Date of Birth * Tribal Enrollment No. * Divider TANF Program Population Information TANF Program Population Information Are you an enrolled member of FCPC? * Yes No Are you a child or grandchild of an enrolled member of FCPC? * Yes No Are you the spouse of an enrolled member of FCPC? * Yes No Do you receive assistance through the General Assistance Program? * Yes No Do you reside within the Forest County Potawatomi reservation? * Yes No Do reside in any of the following counties? Forest Langlade Marinette Oconto Oneida Vilas Are you at least 18 years old? * Yes No Do you have child(ren) in your care or are you pregnant? * Yes No Divider How many children? * 0 1 2 3 4 5 Divider Copy Copy Copy Copy Copy How many children out of Household that TANF individual is paying child support for? * 0 1 2 3 Divider ACKNOWLEDGMENT ACKNOWLEDGMENTAll statements made by me in this application for the Forest County Potawatomi Community (“Tribe”) Temporary Assistance for Needy Families (“TANF”) Program and/or any other documents completed by me in connection with my application are true, complete, and correct to the best of my knowledge. I understand that any false statement, misrepresentation, or omission, regardless of when discovered by the Tribe, may result in my removal from the TANF Program.I understand that any offer of acceptance or placement into the TANF Program is conditioned upon passing of a work program drug screening and background check. I acknowledge that my participation with the TANF Program may end at any time for any reason. By typing my name below, I acknowledge and understand I am using my typed name below as my digital signature. * Applicant Name (Digital Signature) * Date * If you are a human seeing this field, please leave it empty.
