Release of Info

Release of Information

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Name *

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Last

NOTIFICATION TO CLIENT
PRIVACY ACT STATEMENT
25 CFR Part 20 and 25 U.S.C. 13 authorize the collection of this information. The information is confidential and is never
disclosed without written clearance and consent of the applicant. The primary use of this information is to determine eligibility
for financial assistance and services for the Bureau of Indian Affairs (BIA) Child Welfare, Burial and Disaster Assistance
Programs. Additional disclosures of this information may be to other BIA or tribal officials in the conduct of their official duties
pertaining to the application for financial assistance or services, or in the conduct of program review and to the Office of
Inspector General or the General Accounting Office when conducting an audit of BIA Programs, or local Law Enforcement agency
when the agency becomes aware of violation or possible violation of civil or criminal law, and to the General Services
Administration in connection with its responsibility for records management. This information will be entered into the BIA,
Financial Assistance and Social Services – Case Management System, Interior/BIA-8 (76 FR 56787), which can be obtained upon
request from the Chief, Division of Human Service, 1849 C Street, N.W., MS-4513-MIB, Washington DC 20240. No record
contained therein may be disclosed by any means of communication to any person, or to another agency, except pursuant to a
written request by, or with prior written consent of the individual to whom the records pertains. Executive Order 9397
authorizes the collection of your Social Security number. Furnishing the information is voluntary but failure to do so may result
in disapproval of your application. If the BIA uses the information furnished on this form for purposes other than those
indicated above, it may provide you with an additional statement reflecting those purposes.
Under the Privacy Act, BIA may not give out information you give the social service worker except that BIA may share the
information with other Federal, State, and Tribal offices and programs who have some responsibility with the social services for
which you are applying. The information can also be given to those agencies when you ask them for a job or some other benefit
and for law enforcement purposes. This can be done without your consent. For any other person or program wanting
information from your case file, you must first give your written consent. You have the right to know what information is in
your case record and you can ask to see it. If you believe some information in your case file is inaccurate, ask your caseworker
about how to change the information in the case record.
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 devise a material fact, or makes or uses any false writing or 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 five years or both.
PAPER WORK REDUCTION ACT STATEMENT
This information is being collected to determine applicant eligibility for financial assistance and services and to provide Bureau
of Indian Affairs (BIA) managers with information for program planning, reporting and utilization. Response to this collection is
required to obtain benefits under 25 CFR 20. A Federal Agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a currently valid OMB control number. Public reporting for this form is
estimated to average 30 minutes per response, including the time for reviewing instructions, gathering and maintaining data,
completing the form. Direct comment regarding the burden estimate or any other aspect of this form to: Information Collection
Clearance Officer, Office of Regulatory Affairs & Collaborative Action – Indian Affairs, 1849 C Street, N.W., MS-3071-MIB,
Washington, D.C. 20240.
DECISION
When you file an application for social services, you have a right to a written decision within 30 days. In some cases, it may take
45 days. If you disagree with the decision, you may have a review of the decision by seeing your Human Services worker or
supervisor. You also may file an appeal and have a hearing. An applicant or recipient must pursue the appeal process applicable
to the Public Law 93-638 contract, Public Law 102-477 grant, or Public Law 103-413 Self-Governance Annual Funding
Agreement. The regulations for Human Services are in Title 25, Code of Federal Regulations, Part 20.
The amount of grant assistance you may receive or authorize to be expended is based on State Standards of Public Assistance
and/or the rates established by the Assistant Secretary - Indian Affairs, minus your income and available resources. The
information you give must be accurate. If your circumstances change, you must report this immediately to your Human Services
office. By doing so, your Social Services worker can give you proper assistance you are eligible to receive.
Within the limits of its authority, the Human Services Office wants to help you. Ask your Human Services worker to more fully
explain any of this information. If you give inaccurate information and receive assistance to which you are not entitled, you will
be required to pay it back.
ELIGIBILITY
INDIAN BLOOD (25 CFR §20.100)
Applicant must (1) be a member of a federally recognized Indian Tribe, or (2) in the Alaska service area only, any person who
meets the definition of “Native” as defined under 43 U.S.C. 1602(b): “a citizen of the United States and one-fourth degree or more
Alaska Indian.” It includes, in the absence of proof a minimum blood quantum, any citizen of the United States who is regarded
as an Alaska Native by the Native village or Native group of which he claims to be a member and whose father or mother is (or, if
deceased, was) regarded as native by a village or group.
RESIDENCY (25 CFR §20.100 & §20.300)
To be eligible for assistance or services, an applicant must reside in a designated service area.
ELIGIBILITY FOR OTHER SERVICES
Applicant must not be receiving or eligible to receive County/State Public Welfare or Social Security Income. An individual or
family who is presumed to be eligible for these programs may, after providing evidence of having applied for those benefits, be
granted General Assistance (GA), pending approval of such application. Also, all clients applying for GA who are eligible for
assistance from other programs such as Social Security, Unemployment Benefits, Worker’s Compensation, Veteran Benefits,
Retirement, etc., will be required to seek and show that they have applied for that assistance. The BIA Financial Assistance and
Social Services programs are a secondary resource and cannot be used to supplant or supplement other programs.
POLICY ON EMPLOYMENT: ACCEPTANCE OF AVAILABLE EMPLOYMENT (25 CFR §20.314)
An applicant must actively seek employment including the use of available state, tribal, county, local or Bureau-funded
employment services, which they are able and qualified to perform. This means that a recipient, prior to and after applying for
GA, must continue to actively seek employment. An applicant or recipient of GA who is determined employable must also accept
local and seasonable employment when it is available. According to 25 CFR §20.316, the recipient must demonstrate that they
are actively seeking employment by providing the Human Services worker with evidence of job search activities as required in
the Individual Service Plan (ISP) and if they do not seek available local and seasonal employment or quit a job without good
cause, they cannot receive GA for a period of at least 60 days but not more than 90 after they refuse or quit a job.
Applicants must report all current and expected employment and income. Those claiming temporary or permanent disability
are required to present documented medical verification of such disability.
REPORTING REQUIREMENTS
It is the responsibility of all Financial Assistance applicants to report and present appropriate documentary verification of any
and all changes that may occur in their income or living arrangements. Failure to do so may constitute fraud and be subject to
prosecution and/or repayment of disbursements. Each of the following must be reported as they occur:
A move from one residence to another

Addition to or reduction in household members
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Payments received from boarders or lodgers
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Changes or adjustments in housing or Utility Costs
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A move from the Reservation Area, Designated Service Area, or Alaska Native Village

IMPORTANT: Once you have finished reading the Notification to the Client you must sign and date Page 4 of the
Application and check that you have read and understand all provisions of the Privacy Act/FOIA, the Fraud Statement,
the Paperwork Reduction Act, and sign the Release of Information Statement.

Applicants Full name *

RELEASE OF INFORMATION
You grant and authorize the exchange of information between the BIA/ Tribal Human Services Program and the following
agencies/programs:
Tribal/State Employment Offices
Tribal/State Alcohol & Drug Programs
Tribal/State Social Services Programs
Tribal/State Housing Programs
Social Security Administration
Veteran’s Administration
Tribal/State Education Programs
Tribal/State Federal Probation Programs
Tribal/State/Federal Courts
Tribal/State Child Protection Services
Tribal/State Medical Services
Tribal/State Mental Health Services
Tribal Enterprises
Tribal/State Voc-Rehab Programs
Alaska Native Corporations
Indian Health Services
State/County Fiduciary Trust Offices

Any information exchanged will pertain to your eligibility to receive Financial Assistance and Social Service benefits or referral
to other programs that would benefit you. By signing on the statement of cooperation (Page 3 of the Application) you agree and
understand any information obtained will be kept confidential and will be used only for the purposes directly connected with
providing benefits or services on your behalf. You further agree and understand that any information obtained may be released
to proper governmental agency, court, or law enforcement agencies for purposes of legal and investigative action concerning
fraud.
This Release of Information will remain in effect for one (1) year from date of signature or until you request to rescind
authorization.
I authorize the Social Services Program to obtain and/or exchange information necessary to establish eligibility for Financial
Assistance and Social Services.

Applicants Full name *

Submit