Eligibility Changes
• Enrolled Lower Elwha Tribal Members must live within the LEKT Services Area.
• The service area for all applicants enrolled as members in other federally-recognized Indian Tribes is the Lower Elwha Reservation.
Full Name of Applicant (Required)
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Do you live in Clallam County? To be eligible for LEKT GA Services as a enrolled member of another federally-recognized Indian Tribe you must reside on the Lower Elwha Reservation.
Housing (Required) Physical Address (Required) LEKT GA Applicants must live within the LEKT Services Area in Port Angeles, WA.
Mailing Address Gender (Required) Marital Status (Required) Applicant Tribe (Required) Disabled? (Required) For Women, are you pregenant? (Required) If Yes, apply for TANF Services
Household Member 1 Name
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Date of Birth
Household Member 2 Name
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Date of Birth
Household Member 3 Name
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Date of Birth This field is hidden when viewing the form
Does this person receive income? Earned or unearned income
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Income Types
Household Member 4 Name
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Date of Birth This field is hidden when viewing the form
Does this person receive income? Earned or unearned income
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Income Types
Household Member 5 Name
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Date of Birth This field is hidden when viewing the form
Does this person receive income? Earned or unearned income
Do you or your spouse have any form of earned or unearned income at this time? (Required) If yes, complete Sections below for Earned & Unearned Income. If no, please read the following statement and initial afterwards. Both Head of Household and Significant Other must initial.
Type of Income
At this time, I attest that I receive no form of earned and/or unearned income. Applicant Initials (Required)
Earned Income Has anyone stopped working in the last 30 days? (Required) Who stopped working?
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Do you and/or your spouse have any form of unearned income at this time? (Required) If yes, complete additional information
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Unearned Income type Whose Income
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Do you and/or your spouse have any Resources to report (Required) If yes, complete additional information
Who owns the Resource
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Do own a vehicle? (Required) Primary Vehicle (Required) 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.
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Make (Toyota)
Model (Tacoma)
EDUCATION INFORMATION Have you received your High School Diploma? (Required) Have you received your GED? (Required) Are you a FULL time student? (Required) Type of School Employment background (Types of jobs you have held in the past)
EDUCATIONAL OR EMPLOYMENT GOALS Please describe your short and long term goals for education/employment so we can write these into your individual responsibility plan, should you be found eligible for the program.
MEDICAL EXMPETION STATEMENT Please describe what your medical condition is; how this makes you unable to work and the date of the onset or length of time you have been considered medical exempt. Please have your medical provider / physicians complete the medical provider/physician report or provide documentation. If documentation is not provided, you will be required to participate in work like activities until received. If medical exemption is longer than 90 days, please understand you will be required to apply for SSI benefits.
Signature (Required) The following information can be transferred from my application to my housing landlord statement. Main Heating Source is Signature 