Hot Water Tank Application

Please note: the below services are only available to those within the specified services area: (map or list of counties)

URL

This field is for validation purposes and should be left unchanged.

Today's Date(Required)

Name(Required)

First Last

CDIB #(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

DOB(Required)

Phone(Required)

Email(Required)

WK#

Type of assistance requested:(Required)

Hot Water Tank

Please state your problem:(Required)

Must provide documentation of Home Ownership or documentation of Purchasing.
The homeowner must be an enrolled Tribal Member with a CDIB card.
All documentation is to be included with the application. If the amount for the tank and installation exceeds the $750 allowable for O&M Services, the remaining balance is to be paid from the Direct Client Services line item.

File Upload

Drop files here or

Accepted file types: doc, docx, pdf, heic, Max. file size: 10 MB.

Please upload your receipt and any supporting documents.

Reimbursement

Original receipt must be turned in at the time of application submission, along with any supporting documentation.

Requests Payments Be Made To:

Address

Street Address Address Line 2 City State ZIP Code

Vendor Information

Requests Payments Be Made To:

Address

Street Address Address Line 2 City State ZIP Code

Signature(Required)

Today's Date(Required)