By signing below, I __________________________________________ (print name) certify that the
above information is true and correct to the extent of my knowledge. I understand that knowingly
submitting false information may be considered a crime under tribal and federal law. I further agree that
the funds distributed by the Tribe shall be used for General Welfare and only to purchase essential goods
and services to relieve the impacts of COVID-19 and shall not be spent on ineligible expenses.
Limitations: The following is a non-exhaustive list of eligible expenses for which the financial relief under
this program may be used. Eligible expenses are only those which are incurred by you because of the
COVID-19 public health emergency, between March 1, 2020 and December 30, 2020.
i. Groceries, food, meals, and nutrition assistance costs necessary to sustain health and well-being;
ii. Personal care items such as face masks, sanitizer, hand cleaner, hygiene products, and special
clothing necessary to maintain personal health and safety of oneself and others;
iii. Transportation costs including private vehicle use at $0.575/mile, car rental, car service, or
public transportation costs for increased distances and frequency of trips to access essential
and/or emergency services. This may also include assistance with car payments if necessary to
iv. Utility costs for the added expenses incurred to stay at home, isolate or adhere to public health
and Tribal government mandates and recommendations, including electricity, gas, propane,
firewood, water, sewer, waste disposal, internet, and phone.
v. Dependent care, including childcare services and added costs for care and feeding of children not
able to attend school;
vi. Unreimbursed medical and health-related expenses, in addition to costs of in-home care,
prescriptions, supplements, wellness, and counseling;
vii. All expenses related to online learning and expenses to maintain and support the education needs
of school-age children, including post-secondary school
viii. Costs incurred to improve or create teleworking capabilities;
ix. Housing assistance to avoid foreclosure or eviction; and
x. Housing maintenance including cleaning supplies and cleaning services necessary to maintain
sanitary and safe living conditions.
Each individual receiving these funds is personally responsible for using those funds in the manner
prescribed herein and is personally responsible for accounting for those expenditures should they be
called upon to do so by the Tribe, the IRS or another arm of the federal government. You are required
to keep receipts for five (5) years.
By signing, you attest to your qualifications for this grant.
Signature of Applicant Date
FOR OFFICIAL USE ONLY