General Welfare Consolidated Assistance

Check all that apply*

First Time Applicant
Annual Renewal
Address Change
Benefit Amount Change

Personal Information

Name of Tribal Member*

First Last

Enrollment Number*

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I live at the same address as another adult enrolled Snoqualmie Tribal Member:*

Yes
No

Email*

Enter Email Confirm Email

Phone*

Or best contact phone number.

Monthly Benefit Amount Requested*

(adult cannot exceed $3350, elder cannot exceed $3950)

Please enter a number less than or equal to 3950.

Please check “X” the box for each type of assistance for which you intend to use for the general welfare assistance. For all categories checked, you agree that you are the financially responsible party for the expense and supporting documentation will be retained. For households with more than one Adult Tribal Member, invoices or bills from the same vendors will not be accepted as eligible uses of funds.

Housing Assistance

Funds shall only be used to pay for Eligible Expenses at the Tribal Member’s primary residence only.

Basic utility services, specifically water, sewer, trash, electricity, gas, and heat source (natural gas/propane/firewood/pellets); must submit a current utility bill with Tribal Members’ name listed.
Basic communication services, specifically landline and/or cellular telephone, internet, and basic cable services.
Rent/ Mortgage/ Property Taxes/Assisted Living room rent; must submit a lease, mortgage statement, mortgage certification form, property taxes with Tribal Member name.

Health Care Assistance

Funds shall only be used to pay for eligible medical expenses listed below.

Payments for legal medical services rendered by physicians, surgeons, dentists, and other medical practitioners. They include the costs of equipment, supplies, and diagnostic devices intended for these purposes.
Premiums one pays for health insurance that covers expenses of medical care; must provide healthcare insurance card.
Transportation to receive medical care.
Payments for qualified long-term care services and limited amounts paid for any qualified long-term care insurance contract. Traditional medicine and healers, including homeopathic healers, medicine and practices. Wellness Programs, such as gym memberships, purchase of gym/ wellness equipment, and any items that contribute to overall health and wellness not covered by another program.

Food and Clothing Assistance

Funds shall only be used to pay for Eligible Expenses per household.

Food and personal hygiene expenses. (Ineligible: pet supplies, beer/wine/liquor, energy drinks, cigarettes) Clothing expenses.

Elder's Assistance

Funds available only to Elders 55+ (review eligible items on previous page).

I am 55+ and request Elder’s Assistance

Signature

Attach Supporting Documents Here:*

Drop files here or

Accepted file types: docx, doc, pdf, jpg, bmp, gif, png, tif, jpeg, Max. file size: 256 MB, Max. files: 6.

Terms and Conditions

The Snoqualmie Tribal Council wishes to ensure that no tribal member in the community will be without basic fundamental necessities of life. The General Welfare Policy (“Policy”) will not completely fund all members’ financial and other needs but is designed to lessen the burden of living expenses in their everyday lives. It is the intent of the Tribal Council that the Policy be funded from the Tribe’s general fund, which will not be subject to state or federal taxation and will not reduce fixed income or other benefits of the recipients.

I certify the information contained in this application is complete and accurate to the best of my knowledge. I understand that I am signing this application, if I knowingly give false information which results in payment to which I am not entitled, the Tribe may treat the payment as taxable and issue me a Form 1099-MISC and pursue additional disciplinary action including, but not limited to, benefit suspension per the Misuse Policy. I further agree and consent to the confidential release of this application and other materials related to my general welfare benefit use to third parties as may be required in the event of a compliance review.

Acknowledgement*

By checking this box I acknowledge that I have read and agree with the preceding terms and conditions.

I agree

Signature*

Date Signed*