®

Osage Nation
Emergency Assistance

Please take note: FUNDS ARE LIMITED for ONE TIME USE and will
be distributed according to one or more of the following criteria:

1. Elderly
2. Disabled
3. Single-parent families
4. Families with small children

The following documents will be required in order to complete you

Emergency Assistance application:

1. Photo I.D.
2. CDIB/Osage Membership Card
3. Proof of residence
4. All supporting documents relating to your emergency
(receipts, doctors notes, bills, etc.)

All applications must be received by the General Assistance Office at P.O.

Box 522 Hominy, Ok 74035 or may be brought into our office located in the
Industrial Park in Hominy. For questions you may have call (918)287-5325
or our toll free number at 888-822-1248.
 Osage Nation General Assistance
Emergency and Crisis Assistance
(Revised 12/2007)

I. APPLICANT INFORMATION: (Please Print)

Name: Today’s Date:

Physical Address: Phone Number:

Mailing Address: Tribe:

Osage Tribal Member (please circle) YES NO

II. HOUSEHOLD DATA:

Household Members Date of Birth Social Security # Relationship to Applicant

1.

2.

3.

4.

5.

6.

III. Please provide details as to your Crisis or Emergency situation:

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please list what you feel are your immediate needs at this time:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

MY SIGNATURE BELOW ACKNOWLEDGES THE FOLLOWING:

The information I have provided is true and accurate.

Applicant’s Signature Date