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BEAR RIVER BAND of the ROHNERVILLE RANCHERIA COVID-19 (BEAR RIVER BAND OF THE ROHNERVILLE RANCHERIA)

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BEAR RIVER BAND of the ROHNERVILLE RANCHERIA
266 KEISNER RD LOLETA, CA 95551-9707 PHONE 707-733-1900 FAX 707-733-1723
COVID-19 ASSISTANCE APPLICATION
Name: __________________________________________ Enrollment #:__________________
Current Mailing Address:
_________________________________________________________________________
(City)__________________________ (State) _____________ (Zip) ___________________
Phone #: ________________________________ Date of Birth ______/______/__________
Email address: ________________________________________________________________
I am experiencing genuine financial need as a result of the COVID-19 pandemic as follows (check all that
apply):
o I (or someone in my household) became unemployed, had hours cut back, been furloughed or put
on unpaid leave due to COVID-19
o I (or someone in my household) is unable to work or experiencing financial hardship due to no
child care/school due to COVID-19
o I (or someone in my household) has had to close my small business due to COVID-19
o I (or someone in my household) is experiencing significantly increased medical costs or lost
health insurance due to COVID-19
o I (or someone in my household) has had to leave on-campus student housing due to COVID-19
o I (or someone in my household) is experiencing financial hardship due to shelter in place orders
or closures due to COVID-19
o I (or someone in my household) am unable to work because my medical issues prevent me from
returning to the office due to COVID-19 or needing to care for a person with COVID-19
o I (or someone in my household) is experiencing other financial hardship due to COVID-19
(Please explain)
______________________________________________________________________________
______________________________________________________________________________
I certify that the information provided on this application is true and correct to the best of my knowledge.
Sign: ________________________________________________ Date: _________________________
Please return by email to brittanygonzalez@brb-nsn.gov or mail (reference address above)
Attn: Executive Secretary
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BEAR RIVER BAND of the ROHNERVILLE RANCHERIA COVID-19 (BEAR RIVER BAND OF THE ROHNERVILLE RANCHERIA)

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Completed 20 July 2020

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