Exhibit_E_-_Monthly_Tribal_Heating_Assistance_Program_Client_Log.docx
DOCX document 18 KB Posted
- Attached to
- Master Agreement AZ|CTR075550
- Contract number
- CTR075550
- Issued by
- Arizona
About this file
The document is a monthly client log form for the Child and Community Services Division's Tribal Heating Assistance Program, designed to track heating assistance provided to tribal communities. The form appears to be a standardized documentation tool effective July 2023, used to record client details and assistance parameters for a heating support initiative.
The log captures comprehensive client information including monthly gross income, household composition (total members, seniors, children, disabled individuals), main heat source, whether A16 assistance was provided, and records of cords received. The form requires a client signature and provides space for aggregating total monthly data, suggesting this is part of a structured assistance tracking and reporting process for tribal heating support services.
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Text version
Child and Community Services Division Tribal Heating Assistance Program
Client Log - For Month/Yr ________________ Site_______________
| Date |
| Name |
| Main Heat Source |
| A16 Provided? |
| Monthly Gross Income |
| # HH Members |
| # Seniors |
| # Children |
| # Disabled |
| Cords Rec’d |
| Signature |
Totals
Form effective July 2023
File details come from the government source that posted it. Updated .