BOIS FORTE ELDERLY NEEDS PROGRAM

 

Purpose:           The purpose of the Bois Forte Elderly Needs Program is to assist Bois Forte Elderly or Handicapped/Disabled adults who have needs that cannot be met by other programs and resources.  It is intended to be a “last resort” program and applicants must apply to other agencies and be denied.

 

Who is eligible?

                          Bois Forte Band members who reside in Saint Louis, Koochiching and Itasca Counties are:

How do I apply for assistant?

Bois Forte Elderly Needs Program

Attn: Program Coordinator

13071 Nett Lake Road, Suite A

Nett Lake, MN 55772

Who do I call with questions?

Questions should be addressed to the Elderly Needs Program Coordinator please call 1-800-223-1041 or 218-757-3295

 

What may I request?

All requests must be for goods or services that contribute to the well-being and/or safety of the applicant.

The following items are the only items available through this program.  If the item is not listed it may not be requested:

Furnace                                         Refrigerator                    W&S Repairs                Washer and/or Dryer                            Water Heater                  Septic Pumping            Kitchen Range/Stove                  Air Conditioner (window mount only)                                      Freezer Upright or Chest    Couch/Sofa                      Main/Storm Door Carpet/Floor Covering        Recliner                           Handicap Accessibility Needs          Kitchen Table/Chair Set    Ramp                                 Bed and/or Dresser Set           

Are there any other things that I cannot request?

Yes. This program will not pay your utility bills (electricity, heating fuel of any kind, water, community sewer, or phone bills).

This program will not pay for anything intended as a gift for another or that will be used primarily by someone who is not an eligible applicant.

How much assistance can I get?

The program will provide assistance of up to $600.00 per household (with a minimum of $50.00) towards the purchase of 1 item listed above.

If the cost of the item exceeds $600.00 it will be the applicant’s responsibility to pay remainder of the balance and you must demonstrate the ability to pay the remaining balance.

If I already purchased a qualifying item can I apply for help in paying for it?

                            No.  The program does not allow for reimbursements.

How often can I apply?

After receiving assistance you will be eligible again in two (2) calendar years after your award, unless, the request is for an emergency that was beyond your control.

BOIS FORTE

ELDERLY NEEDS PROGRAM

APPLICATION

 

Name_______________________________                            D.O.B.___________________________

 

Address_____________________________                 Phone #_________________________

 

____________________________________                            Bois Forte Enrollment #______________

 

Are you disabled or handicapped? _____ Yes _____No (if yes please attach proof)

 

Do you ____ Rent or ____ Own your home?

 

Amount requesting ($600.00 Max) $________ for item checked below: (attach vendor quote)

( )Furnace         ( )Refrigerator                            ( )W&S Repairs             ( )Water Heater           ( )Ramp

( )Washer and/or Dryer          ( )Septic Pumping        ( )Kitchen Range/Stove           ( )Recliner

( )Air Conditioner        ( )Couch/Sofa                 ( )Main/Storm Door                  ( )Accessibility Needs

( )Freezer Upright or Chest     ( )Carpet/Floor Covering        ( )Kitchen Table and Chair Set

( )Bed and/or Dresser Set

 

Income (Social Security, SSI, Wager, Unemployment, Retirement etc.) Please attach check stub, letter, and statement.

 

Income Source:______________________________________Amount$__________________

Income Source:______________________________________Amount$__________________

Income Source:______________________________________Amount$__________________

                                                                                           

                                                                                                  Monthly Total $_____________________

 

I, the undersigned, do hereby agree to accept this item and to have sole responsibility of the item.  The above shall remain with me in my place of residence.  I also verify that the above is true and correct to the best of my knowledge.

 

Applicant Signature:_______________________________________Date:_________________

 

For Office Use Only

Approved: ____Date:__________

Table:         ____Date:__________

Denied:      ____Date:__________

Revised 10/12