YUROK TRIBE ENVIRONMENTAL PROGRAM

190 Klamath Boulevard, Klamath, California 95548

(707) 482-1350 / (707) 488-2106 (FAX)

APPLICATION FOR SOLID WASTE ASSISTANCE

Yurok Tribal Members experiencing financial hardship are encouraged to apply for assistance from YTEP for removal of solid waste. In addition to up to $500 in property cleanup assistance, funds are available to subsidize bulky item and curbside garbage disposal services through YTEP. In order to qualify for these services, your household must satisfy the income eligibility requirements established for the current year by the Office of Housing and Urban Development. The requirements for the current year for Humboldt and Del Norte Counties are attached.

In addition to filling out this form, you must include income verification. Income verification includes your most recently completed tax return and copies of your two most recent income sources (paycheck stubs, financial assistance stubs, etc.). YTEP will provide a sliding scale of assistance to Tribal Members depending on their income. More information on assistance levels is attached.

Should you qualify to receive services from YTEP, you may be asked to contribute voluntary labor to solid waste cleanups in your area. If you are not physically able to contribute to these efforts, YTEP may request that you provide volunteer time to tutor Tribal youth or otherwise become involved with community improvement projects. The limit for the amount of time YTEP may ask you to contribute annually is also attached.

Every Tribal Member receiving assistance from YTEP will be required to sign an assistance agreement acknowledging their receipt of Tribal Ordinances and their understanding that they are expected to abide by those ordinances to protect the health of the Yurok Indian Reservation.

DATE:______

NAME:______

ADDRESS:______

TELEPHONE:______

TRIBAL ID#: ______

BIRTH DATE:______

SIGNATURE:______

***continued on the reverse side***

ASSISTANCE NEEDED:

__ Curbside Garbage Disposal

__ Appliance Removal (please specify the number and type of appliances)

______

______

__ Trailer demolition and removal (please specify number of trailers: _____)

__ One-time waste hauling (please specify amount and type of waste)

______

______

Property Ownership Type:

__ I own this property in fee

__ I own this property in trust

__ This property is an assignment

Declared Household Income (Annually): $______

Number of people in your household: ______

YTEP Assistance Levels

Based upon Housing and Urban Development Assistance Levels for Humboldt and Del Norte Counties

# in household: / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8
100% Subsidized / $10,300 / $11,800 / $13,250 / $14,750 / $15,900 / $17,100 / $18,250 / $19,450
75% Subsidized / $17,200 / $19,650 / $22,100 / $24,550 / $26,500 / $28,500 / $30,450 / $32,400
50% Subsidized / $27,500 / $31,400 / $35,350 / $39,300 / $42,400 / $45,550 / $48,700 / $51,850

*Example: A two person household with a combined household income of $19,000 per year would qualify for YTEP assistance with 75% of curbside garbage disposal costs.

Volunteer Assistance Limits

YTEP may request your assistance on community cleanup activities at a rate of 1 hour for every $7 in assistance provided. Should YTEP request your assistance on a cleanup effort and you fail to provide YTEP with a reasonable excuse for not attending, YTEP reserves the right to withhold assistance in the future.

For YTEP use only:NUMBER: ______

__ Site Visit

__ Cleanup Costs Estimated ($______)

__ Income verified

__ Assistance level: ______

__ Assignment status

__ N/A

__ Renewal applied for

__Renewal not due

__ Renewal required

Completed by: ______Approved by: ______