Fillable COVID-19 RELIEF FUND DISTRIBUTION APPLICATION FORM (Chickaloon Native Village)

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COVID-19 RELIEF FUND DISTRIBUTION APPLICATION FORM (Chickaloon Native Village)

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COVID-19 RELIEF FUND DISTRIBUTION APPLICATION FORM
Full Name of
Tribal Citizen:
Date of Birth:
Mailing
Address:
Street/P.O. Box:
City/State:
Zip:
Home Phone:
Cell Phone:
E-Mail:
Dependent Child’s Name:
Child’s Date of Birth
Dependent Child’s Name:
Child’s Date of Birth
Dependent Child’s Name:
Child’s Date of Birth
Dependent Child’s Name:
Child’s Date of Birth
Dependent Child’s Name:
Child’s Date of Birth
Dependent Child’s Name:
Child’s Date of Birth
Dependent Child’s Name:
Child’s Date of Birth
Dependent Child’s Name:
Child’s Date of Birth
(Attach an additional page as needed for more dependents.)
You will be contacted once your application has been received to verify information and confirm payment
distribution method. Completed applications will be accepted no later than June 30, 2020, using one of
the following methods:
Mail:
Chickaloon Village Traditional
Council
PO Box 1105
Chickaloon, Alaska 99674
In-Person:
Ceghaznae Hwnax
(Drop Box)
9255 N Glenn Hwy
Palmer, Alaska 99645
Email:
cvadmin@chickaloon-nsn.gov
Fax:
907-745-0709
Or call CVTC Administration for further assistance (907) 745-0749.
This Section for CVTC Office Use Only:
Date Received: _
____________________________________
CC: Lisa Wade and Council Executive Assistant
Citizenship Verified by Lisa Wade: ______
Information Verified by Council Executive Assistant: ______
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COVID-19 RELIEF FUND DISTRIBUTION APPLICATION FORM (Chickaloon Native Village)

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Completed 20 July 2020

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