Verification of Monetary Distribution Fillable Form

Please complete the following form. The completed form will be emailed to the email you have specified. Please upload the form in your TANF application or in the upload portal.

Please contact 406-395-5814 or TANFInfo@chippewa-cree.org for questions or concerns regarding this process.

Applicant Name(Required)

First Last

Certification(Required)

I am a Chippewa Cree Tribal TANF Program (CCTTP) client. In order to process my application or to continue receiving assistance with the CCTT Program, my case manager will need to verify if I receive per capita, and/or any other monetary distributions from my Tribe. Please provide the type and reoccurrence of any monetary distributions on my behalf for the CCTT Program by filling out the below information for me to give to my case manager. If you should have any questions, please contact the Chippewa Cree Tribal TANF office at (406) 395-5814.

In order to protect your private information the completed PDF form will be encrypted with a password. Please type a password you can remember.

Password(Required)

The completed PDF form will be emailed to you please provide an email address below.

Email(Required)

Applicant Signature(Required)

Applicant Date Signed(Required)

MM slash DD slash YYYY

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