2023 VETERANS CARE ASSISTANCE ACT APPLICATION

VETERANS CARE ASSISTANCE ACT APPLICATION
Office of Veterans Affairs

200 Wolf Robe Circle

P.O. Box 167

Concho OK 73022

Phone (405)422-7724

Fax (405) 422-7789

Email veteranservices@cheyenneandarapaho-nsn.gov
The newly adopted Cheyenne and Arapaho Tribes Veterans Care Assistance Act authorizes $150 per month to be paid to eligible veterans out of the American Rescue Plan Act of 2021 implemented by the 117th United States Congress. In order to receive the monthly assistance, Veterans must meet the following criteria:
- Cheyenne and Arapaho Tribal Member
- Discharged/released from military service under conditions with rating higher than dishonorable
- Completed W9 form
IT IS THE RESPONSIBILITY OF THE VETERAN (or representative) to update this information should contact information change. ALL Applicants will complete a W9 in order to process application and receive the monetary assistance. Applications are processed by the OVA staff at the CONCHO ERC.
Veteran Information

(ALL information is needed, in order to process)
Name of Enrolled Cheyenne and Arapaho Tribal Member Veteran*
Name of Guardian/Designated Representative of Veteran (if applies)*
Last 4 Digits of Social Security*
Date of Birth*

MonthDayYear
Date
Age*
C & A Roll Number*
Mailing Address*

Mailing Address

Street Address Line 2

CityState

Zip
Physical Address*

Physical Address

Street Address Line 2

CityState

Zip
Home Phone*
Cell Phone*
Email*
example@example.com
Alternate Contact Name*
Relationship*
Cell Phone*
AGREEMENT AND SIGNATURE
By my signature below, I agree that the information provided is true and correct.
- I understand the OVA staff will keep all information confidential.
- I understand that my information will NOT be shared with NON-Veteran agency without written consent from me.
- I understand that purposely falsifying this document will jeopardize future services with the Cheyenne and Arapaho Tribes.
- I understand this is not a per capita or stimulus payment and is subject to certification of my military service.I understand that this assistance is provided under the OVA Program, and will not be subject to federal income tax in accordance with the requirements of the Federal Tribal General Welfare Exclusion Act of 2014.
- I understand that monthly assistance is based on availability of funds.
- I will ALWAYS keep my address updated with the OVA office in order to receive this monthly assistance.
- I know lost, mutilated, or stolen checks will not be replaced until a 60-day waiting period has passed, at which time a new check will be issued if the previous check has not been cashed.
- Iunderstand this check is valid for 90 days-no checks will be reissued.
Tribal Member Veteran Signature*

Clear
Date *

MonthDayYear
Date
Should be Empty:

VETERANS CARE ASSISTANCE ACT APPLICATION

Veteran Information

AGREEMENT AND SIGNATURE