Yearly Application for Monthly Food Assistance

Elder Care Program
Yearly Application/Change of Address Form for Monthly Food Assistance
Due by the 14th of the month

In order to be eligible for food assistance, to be mailed each month, you must be an enrolled member of the Cheyenne and Arapaho Tribes and turning 55 or older during the month you apply.

APPLICATIONS ARE PROCESSED IN THE CONCHO OFFICE
Name*

First NameLast Name
Always provide your CDIB#*
If you are NEW to the program, upload a copy of your CDIB

Browse Files

Cancelof
Date of Birth*

MonthDayYear
Spouse's Name

First NameLast Name
We do not mail checks to jails, prisons, homeless/day centers, general delivery addresses, or hotels/motels.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Message Phone Number*

Area CodePhone Number
Email
example@example.com
Remember:
- ALWAYS keep your address updated—every time you move, as soon as you move, update with Elder Care & Enrollment! If we don’t receive your updated application by the 14th of the month, your check will go to previous address.
- New clients to Elder Care must submit their application by the 14th of the month BEFORE you turn 55 years old.
- 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.
- Checks are valid for 90 days—no checks will be reissued.
Tribal Member Signature*

Clear
Today's Date*

MonthDayYear
**RETURN BY THE 14TH OF THE MONTH IN ORDER FOR THE FOOD CHECK TO BE PROCESSED THE FOLLOWING MONTH**
Should be Empty:

Elder Care Program

Yearly Application/Change of Address Form for Monthly Food Assistance