HOOPA VALLEY TRIBAL COUNCIL
Hoopa Valley Tribe
Post Office Box 1348 Hoopa, California 95546
PH (530) 625-4211 • FX (530) 625-4594
www.hoopa-nsn.gov
Chairman Byron Nelson, Jr.
2020 Hoopa Valley Tribe COVID-19 General Welfare Assistance Intake Form
This form will be used for Hoopa tribal internal use only.
This information contained on this form is not for distribution to any outside agency or entity.
Na
me: _____________________________________________ Date of Birth: _____________________
Enrollment No.: ________________________________ Phone No.: _____________________________
Add
ress: _____________________________________________________________________________
Ci
ty, State, Zip: _______________________________________________________________________
Legal Dependent(s) Name: _________________________________ Enrollment No.: _______________
N
ame: _________________________________ Enrollment No.: _______________
Name: _________________________________ Enrollment No: _______________
For additional Legal Dependents, please submit an additional sheet as an attachment.
I a
m experiencing genuine financial need as a result if the COVID-19 pandemic as follows (check all that apply):
__
___
I (or someone in my household) became unemployed, had hours cut back, been furloughed, or put on
unpaid leave due to COVID-19.
_____
I (or someone in my household) is unable to work or experiencing financial hardship due to no childcare
__
___
I (or someone in my household) is experiencing significantly increased medical cost or lost health
insurance due to COVID-19.
__
___
I (or someone in my household is 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.
_____
I (or someone in my household) is experiencing financial hardship due to shelter in place orders or
closures due to COVID-19.
_____
I (or someone in my household) is experiencing other financial hardship due to COVID-19 (Please
explain). ___________________________________________________________________________
____________________________________________________________________________
I hereby accept this one-time receipt of COVID-19 assistance distribution, and I will use this assistance to supplement my
basic expenses and needs due to the financial hardship as a result of COVID-19, such as paying for rent, utilities, mortgage
payments, essential food and supplies, health care, funeral support, and cultural activities. By my signature below, I declare
that all of the above statements are true and accurate.
Please be advised that this Assistance Intake Form must be completed and returned to hvt.carrie.ames@gmail.com
or mailed to
Hoopa Valley Tribal Fiscal Department, P.O. Box 1348, Hoopa, CA 95546 to determine you or your Legal Dependents’
eligibility for receipt of the 2020 Hoopa Valley Tribe COVID-19 Assistance Distribution.
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