Application for Child Only Case (Non-Needy Caretaker Relative)

Child Only Cases are available to families who have had children placed with them or for which they are otherwise activing as a caregiver. They are also available to one-parent families with biological or adopted children in which the parent receives Supplemental Security Income (SSI) Benefits. For Child Only Cases, monthly cash grants are issued to assist with the basic needs of the children in the family unit.

To avoid delays in determining eligibility, applications must be complete and the following documentation must be submitted:

Certificate of Indian Blood (CIB) for at least one person in the family unit.
Placement paperwork from the agency through which the children were placed or a completed Statement of Adult Acting in Loco Parentis Form.
Families who have children, ages 6 through 18 years, must submit proof of school enrollment and two weeks of attendance. This requirement does not apply to families who apply over summer break unless it is required as a stipulation of a previous case.
If there is income for the children or biological or adoptive parent, verification must be provided along with the application. Based upon the type, income may be counted when determining eligibility and calculating the monthly cash grants. If countable, the income must not exceed the limits for the family unit size.

Family Unit Size	Monthly Income Limit	Family Unit Size	Monthly Income Limit
1	$1,000	6	$2,000
2	$1,200	7	$2,200
3	$1,400	8	$2,400
4	$1,600	9	$2,600
5	$1,800	10	$2,800

For all required documentation, please ask if you need assistance in acquiring or do not understand what it is that you must provide. All applications and documentation can be submitted by emailing to TANF@quinault.org.

If you would prefer to download and print this application to submit by email or in person, please click here.

Important

An email address is required for this form to be HIPAA compliant. If you do not have an email address, please call the office for assistance in setting up an email address.

Head of Household

First Name(Required)

Middle Name

Last Name(Required)

Suffix (Jr, SR, II)

Alternate Names

Gender(Required)

Male

Female

Date of Birth(Required)

Social Security #(Required)

US Citizen?(Required)

Yes

Tribal Affilation

Enrollment #

Disabled?(Required)

Yes

Pregnant?(Required)

Yes

If Pregnant, Due Date

Physical Address(Required)

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Phone Number(Required)

Email Address(Required)

Marital Status(Required)

Single, Never Married

Married

Seperated

Divorced

Widowed

Highest Education Level Completed(Required)

Less than High School Diploma or GED

High School Diploma or GED

Associates Degree

Bachelor’s Degree

Graduate/Master’s Degree

Other Credentials (Ex. CDL, Vocational Certifications, etc.)

Do you have a Spouse or Significant Other?(Required)

Yes

Spouse/Significant Other

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Alternate Names

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Pregnant?

Yes

If Pregnant, Due Date

Phone Number

Email Address

Marital Status

Single, Never Married

Married

Seperated

Divorced

Widowed

Highest Education Level Completed

Less than High School Diploma or GED

High School Diploma or GED

Associates Degree

Bachelor’s Degree

Graduate/Master’s Degree

Other Credentials (Ex. CDL, Vocational Certifications, etc.)

Child #1

First Name(Required)

Middle Name

Last Name(Required)

Suffix (Jr, SR, II)

Relationship To Household(Required)

Gender(Required)

Male

Female

Date of Birth(Required)

Social Security #(Required)

US Citizen?(Required)

Yes

Tribal Affiliation

Enrollment #

Disabled?(Required)

Yes

Teen Parent(Required)

Yes

Pregnant?(Required)

Yes

If Pregnant, Due Date

Father's Name(Required)

Father's Status(Required)

In Home

Absent from Home

Deceased

Mother's Name(Required)

Mother's Status(Required)

In Home

Absent from Home

Deceased

Current Grade Level(Required)

Name of School Where Enrolled/Attending(Required)

Do you have additional children to add?(Required)

Yes

Child #2

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Relationship To Household

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Teen Parent

Yes

Pregnant?

Yes

If Pregnant, Due Date

Father's Name

Father's Status

In Home

Absent from Home

Deceased

Mother's Name

Mother's Status

In Home

Absent from Home

Deceased

Current Grade Level

Name of School Where Enrolled/Attending

Do you have additional children to add?

Yes

Child #3

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Relationship To Household

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Teen Parent

Yes

Pregnant?

Yes

If Pregnant, Due Date

Father's Name

Father's Status

In Home

Absent from Home

Deceased

Mother's Name

Mother's Status

In Home

Absent from Home

Deceased

Current Grade Level

Name of School Where Enrolled/Attending

Do you have additional children to add?

Yes

Child #4

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Relationship To Household

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Teen Parent

Yes

Pregnant?

Yes

If Pregnant, Due Date

Father's Name

Father's Status

In Home

Absent from Home

Deceased

Mother's Name

Mother's Status

In Home

Absent from Home

Deceased

Current Grade Level

Name of School Where Enrolled/Attending

Do you have additional children to add?

Yes

Child #5

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Relationship To Household

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Teen Parent

Yes

Pregnant?

Yes

If Pregnant, Due Date

Father's Name

Father's Status

In Home

Absent from Home

Deceased

Mother's Name

Mother's Status

In Home

Absent from Home

Deceased

Current Grade Level

Name of School Where Enrolled/Attending

Do you have additional children to add?

Yes

Child #6

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Relationship To Household

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Teen Parent

Yes

Pregnant?

Yes

If Pregnant, Due Date

Father's Name

Father's Status

In Home

Absent from Home

Deceased

Mother's Name

Mother's Status

In Home

Absent from Home

Deceased

Current Grade Level

Name of School Where Enrolled/Attending

Resources and Income Information

Do any of the children in the family unit have resources?(Required)

If Yes, complete below.

Yes

Resources

A resource is anything that is own or is being bought that can be sold, traded, or converted into cash or money held by others. A resource does not include personal property such as furniture or clothing. Example of resources are: Annuities, Checking, Land, Savings Accounts, Bonds, College Funds, Life Insurance, Savings Bonds, Buildings, Condominiums, Money Market Accounts, Stocks, Cash, Houses, Mutual Funds, Time Shares, CD Accounts, IIM Accounts, Sales Contracts, Trusts.

Resource

Who Owns

Location

Value

Primary Vehicle

Please list the primary vehicle that is used to transport the children in the family unit. If you do not have a vehicle, please leave blank.

Vehicle Year

2000

Vehicle Make

Ford

Vehicle Model

Escort

Vehicle Owed Amount

$$$$

Vehicle Payment

$$$$

Vehicle Value

$$$$

Vehicle Mileage

100,000

Vehicle Condition

Fair, Good, Very Good, Excellent

Would you like to add an additional vehicle?

Yes

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Vehicle 2

Vehicle Year

2000

Vehicle Make

Ford

Vehicle Model

Escort

Vehicle Owed Amount

$$$$

Vehicle Payment

$$$$

Vehicle Value

$$$$

Vehicle Mileage

100,000

Vehicle Condition

Fair, Good, Very Good, Excellent

Would you like to add an additional vehicle?

Yes

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Vehicle 3

Vehicle Year

2000

Vehicle Make

Ford

Vehicle Model

Escort

Vehicle Owed Amount

$$$$

Vehicle Payment

$$$$

Vehicle Value

$$$$

Vehicle Mileage

100,000

Vehicle Condition

Fair, Good, Very Good, Excellent

Would you like to add an additional vehicle?

Yes

This field is hidden when viewing the form

Vehicle 4

Vehicle Year

2000

Vehicle Make

Ford

Vehicle Model

Escort

Vehicle Owed Amount

$$$$

Vehicle Payment

$$$$

Vehicle Value

$$$$

Vehicle Mileage

100,000

Vehicle Condition

Fair, Good, Very Good, Excellent

TANF Benefits

Have you, or anyone for which you are applying, received TANF Benefits (monthly cash assistance) from a Federal, State or Tribal Agency in the last 30 days?(Required)

Yes

TANF Benefits

Who Received

When Last Received

Federal/State/Tribal Agency

Have you, or anyone for which you are applying, ever received TANF Benefits (monthly cash assistance) from a Federal, State or Tribal Agency?(Required)

Yes

TANF Benefits

Who Received

When Last Received

Federal/State/Tribal Agency

By typing your initials below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual Initials on this application.

Head of Household Initials:(Required)

I attest that the above information regarding the receipt of TANF Benefits is true.

Spouse Initials:

I attest that the above information regarding the receipt of TANF Benefits is true.

Income Statement

Do you receive any form of income for the children in the family unit?(Required)

If yes, complete the Unearned Income section. If no, please read the following statement and initial afterwards. Both Head of Household and Significant Other must initial.

Yes

Unearned Income

Do you receive any form of unearned income for the child in the family unit?

Yes

Unearned Income

Examples of unearned income are: Alaska Shareholder Dividends, Gifts or Prizes, Rental/Lease Income, Annuities, IIM Accounts, Sale of Property/Timber, Child Support, Inheritance, Settlements, Dividends, Military Allotments, Social Security – Dependent Benefits, Food Stamps, Out of State TANF, Social Security – Survivor Benefits, Foster Care Payments, Per Capita, Supplemental Security Income – SSI, Tribal Lease Payments.

Who Received Income

Income Type

Amount

Frequency Received

Date Received __/__/____

By typing your initials below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual Initials on this application.

Head of Household Initials:

At this time, I/we attest that I/we receive no form of unearned income for the children in the family unit.

Spouse Initials:

At this time, I/we attest that I/we receive no form of unearned income for the children in the family unit.

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Section Break

Child Support Income Statement

Have you or your significant other received child support payment(s) directly from a non-custodial parent in the last 30 days?(Required)

If yes, list the date and amount of the payments that you have received. If no, please read the following statement and initial afterwards. Both Head of Household and Significant Other must initial.

Yes

Date Received

Amount Received

By typing your initials below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual Initials on this application.

Head of Household Initials:

At this time, I/we attest that I/we have not received any child support payments directly from a non-custodial parent in the last 30 days.

Spouse Initials:

At this time, I/we attest that I/we have not received any child support payments directly from a non-custodial parent in the last 30 days.

Statement of Residency

I/We

First Name(Required)

Middle Name

Last Name(Required)

Suffix (Jr, SR, II)

Significant Other

First Middle Last Suffix

Residing Address(Required)

Street Address Address Line 2 City State ZIP Code

I/we have resided at this address for:

WEEKS

I/we have resided at this address for:

MONTHS

I/we have resided at this address for:

YEARS

I/we make rent/lease/mortgage payments to:

Payment Recipient

I/we make rent/lease/mortgage payments in the amount of:

Payment Amount

If you do NOT make payments, check which apply and initial below:

Head of Household Initials:

Spouse Initials:

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Head of Household Signature(Required)

I/we have read (or had explained to me/us) and understand the information in this application. I/we declare under penalty of perjury, that information I/we gave in this application is true, correct and complete to the best of my/our knowledge. I/we understand that if I/we incorrectly receive a QIN TANF cash grant, because I/we have made a willful false statement or because I/we have willfully failed to report information required by the QIN TANF Program, I/we will be required to repay the amount received.

Significant Other Signature

Date of Signature(Required)

Date of Signature

Child Support Referral Information

Please complete the Child Support Referral and Assignment. It will be emailed back to you upon completion. Attach with all other supporting documents at the end of the application. Please know that incomplete referrals and assignments will delay the processing time for a determination of eligibility. Information is required on the custodial parent(s), non-custodial parent(s) and children. If children do not have the same mother and father, a separate referral must be completed.

Mother's Information, if Not Custodian

Is the mother deceased?

Yes

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Deceased section break

Has the mother been deported?

Yes

Name

First Middle Last

Alternate Name(s)

Physical Address

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Phone Number

Message Number

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Race

Height

Weight

Hair Color

Eye Color

Native Language

Identifying Marks

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Lives on an Indian reservation?

Yes

Currently Married?

Yes

If yes, to whom

Employer's Name

Employers Phone

Employer's Address

Street Address City State / Province / Region ZIP / Postal Code

Income

Income Received

Unknown

Per Hour

Per Month

Has a second job?

Yes

If yes, where

Ever been in jail or prison?

Yes

If yes, where

Vehicle Year

Vehicle Make

Vehicle Model

In Military?

Yes

Branch

From

Mother's Parents

If deceased, leave blank.

First Middle Last

Address

If deceased, leave blank.

Street Address City State ZIP Code

Phone Number

If deceased, leave blank.

Message Number

If deceased, leave blank.

Father's Information, if Not Custodian

Is the father deceased?

Yes

This field is hidden when viewing the form

Deceased Section Break

Has the father been deported?

Yes

Name

First Middle Last

Alternate Name(s)

Physical Address

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Phone Number

Message Number

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Race

Height

Weight

Hair Color

Eye Color

Native Language

Identifying Marks

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Lives on an Indian reservation?

Yes

Currently Married?

Yes

If yes, to whom

Employer's Name

Employers Phone

Employer's Address

Street Address City State ZIP Code

Income

Income Received

Unknown

Per Hour

Per Month

Has a second job?

Yes

If yes, where

Ever been in jail or prison?

Yes

If yes, where

Vehicle Year

Vehicle Make

Vehicle Model

In Military?

Yes

Branch

From

Father's Parents

If deceased, leave blank.

First Middle Last

Address

If deceased, leave blank.

Street Address City State ZIP Code

Phone Number

If deceased, leave blank.

Message Number

If deceased, leave blank.

Head of Household Information

First Name(Required)

Middle Name

Last Name(Required)

Suffix (Jr, SR, II)

Alternate Name(s)

Social Security #(Required)

Date of Birth(Required)

Gender(Required)

Female

Male

Physical Address

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Race(Required)

Enrolled member of a federally recognized Indian tribe?(Required)

Yes

If yes, name of tribe

Relationship to Child(Required)

Do you have legal custody?(Required)

Yes

If no, who has legal custody

Is private attorney currently working on your child support case?

Yes

If yes, name and phone number of attorney

Domestic Violence Information

Have you or the child/ren in the household ever experienced any type of abuse?(Required)

Yes

Have you ever had a protective order against you or the non-custodial parent?(Required)

Yes

If yes, what court issued the order?

Do you believe that you or the child/ren may be at risk of emotional and/or physical harm if the non-custodial parent knows where to find you?(Required)

Yes

If yes, do you want to complete a Family Violence Non-Disclosure Statement?

Yes

Child Information 1

Please note that if children have a different mother and father then a separate referral must be completed.

First Name(Required)

Middle Name

Last Name(Required)

Suffix (Jr, SR, II)

Social Security #(Required)

Date of Birth(Required)

Place of Birth City, County, State, Country(Required)

Gender(Required)

Female

Male

Race(Required)

Enrolled member of a federally recognized Indian tribe?(Required)

Yes

If yes, name of tribe

Enrollment Number

Legal Status(Required)

A support order has been issued for this child

Paternity has been established for this child, but no order has been issued

Paternity for this child needs to be established

Parent are living apart and there is no support order

Child Information 2

Please note that if children have a different mother and father then a separate referral must be completed.

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Gender

Female

Male

Race

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Enrollment Number

Legal Status

A support order has been issued for this child

Paternity has been established for this child, but no order has been issued

Paternity for this child needs to be established

Parent are living apart and there is no support order

Child Information 3

Please note that if children have a different mother and father then a separate referral must be completed.

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Gender

Female

Male

Race

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Enrollment Number

Legal Status

A support order has been issued for this child

Paternity has been established for this child, but no order has been issued

Paternity for this child needs to be established

Parent are living apart and there is no support order

Child Information 4

Please note that if children have a different mother and father then a separate referral must be completed.

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Gender

Female

Male

Race

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Enrollment Number

Legal Status

A support order has been issued for this child

Paternity has been established for this child, but no order has been issued

Paternity for this child needs to be established

Parent are living apart and there is no support order

Child Support Obligation

What is the relationship between the mother and father of the child/ren?

Never Married

Married/Living Together

Married but Separated

Divorced

If separated, date of separation

If divorced, date of divorce

Have you ever appeared in court for any of the following reasons?

Check All that Apply

Child Support

Child Custody

Legal Paternity

Divorced

Domestic Violence

Court Orders

Date of Order

Court Case Number

What court issued the order?

City

County

State

If Tribal Court, which Tribe?

Was child support ordered?

Yes

If Yes, how much ordered to pay child support

If Yes, how often ordered to pay child support

Every Week

Every Two Weeks

Every Month

Was a private attorney consulted on this case?

Yes

If yes, name and phone number of attorney

Pending Court Orders

Are there any legal action(s) that may affect the child/ren?

Yes

Is the child/ren in Indian Child Welfare (ICW) or Child Welfare custody?

If yes, complete the following information.

Yes

Date child/ren were placed in ICW/CW custody

If child/ren are in ICW care, with what Tribe?

Date Filed

Court Case Number

City

County

State

What court was the paperwork filed at?

If Tribal Court, which Tribe?

Was a private attorney consulted on this case?

Yes

If yes, name and phone number of attorney

Modification of Child Support

Date of Order

Court Case Number

What court issued the order?

City

County

State

If Tribal Court, which Tribe?

Were modifications made to the Child Support Order?

Yes

If modified, indicate how much

If modified, indicate how often

Every Week

Every Two Weeks

Every Month

Was a private attorney consulted on this case?

Yes

If yes, name and phone number of attorney

Additional Forms

Required Child Support Assignment

Complete this form for all applications. Click HERE to open the form in a new tab. Fill out the form completely, sign and submit. The completed form will be emailed to you and can then be attached to this application.

Required Statement of Adult Acting in Loco Parentis

Complete this form if there is no legal documentation for the placement or custody of the children. Click HERE to open the form in a new tab. Fill out the form completely, sign and submit. The completed form will be emailed to you and can then be attached to this application.

Required Release of Information

This form is required for all applications. Click HERE to open the form in a new tab. Fill out the form completely, sign and submit. The completed form will be emailed to you and can then be attached to this application.

Required Payment Form

Optional Authorization Agreement for Direct Deposit

Complete this form if Direct Deposit was selected as the payment type in the Payment Form. Click HERE to open the form in a new tab. Fill out the form completely, sign and submit. The completed form will be emailed to you and can then be attached to this application.

Optional Key2Benefits Cardholder Form

Complete this form if Debit Card was selected as the payment type in the Payment Form. Click HERE to open the form in a new tab. Fill out the form completely, sign and submit. The completed form will be emailed to you and can then be attached to this application.

Required W9 Release of Taxpayer Information

This form is required for all applications. Click HERE to open the form in a new tab. Fill out the form completely, sign and submit. The completed W9 will be emailed to you and can then be attached to this application.

File Upload

Files can be uploaded, brought into the office or emailed separately to TANF@quinault.org

Drop files here or

Max. file size: 40 MB, Max. files: 40.