Fillable OREGON EMERGENCY COVID-19 RELIEF PROGRAM (City of Oakland)

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OREGON EMERGENCY COVID-19 RELIEF PROGRAM (City of Oakland)

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1
APPLICATION FOR EMERGENCY COVID-19 RELIEF ASSISTANCE
The Oregon Legislature has approved a program to provide financial relief to Oregonians who have
experienced an economic hardship due to COVID-19. You may be eligible for a one-time, $500 emergency relief
payment if the criteria in each section below apply to you. Funds are limited and may be considered taxable
income.
SECTION ONE: IF YOU ANSWER “YES” TO ALL QUESTIONS IN THIS SECTION YOU MAY BE ELIGIBLE
FOR THE PROGRAM SUBJECT TO THE AVAILABILITY OF FUNDS, PLEASE MOVE ON TO SECTION
TWO. IF YOU ANSWER “NO” TO ANY OF THE QUESTIONS IN THIS SECTION, YOU ARE NOT
ELIGIBLE FOR THIS PROGRAM.
YES NO
Prior to experiencing severe financial hardship due to COVID-19, my income before any
deduction for taxes, insurance, or retirement contributions was not more than $4,000.00 per
month. (Note to applicant: if your income varies due to commissions, tips, or because you are
self-employed, your answer should be based on the last six months before your income was
affected by COVID-19.)
I am 18 years or older and am applying for these funds on my own behalf. (Note to applicant:
You may only apply for funds on your own behalf and must provide acceptable
documentation, such as an Oregon state driver’s license or ID card, passport, or other
government photo ID. See pages 4-5 for a list of acceptable documents.)
My primary residence is in Oregon. (Note to applicant: if the documentation used for the
above question does not include a current address, please provide additional documentation
such as a piece of mail with your name and address. See below for full list of acceptable
documents).
OREGON EMERGENCY COVID-19 RELIEF PROGRAM
HTTPS://EMERGENCYCHECKS.OREGON.GOV
I am experiencing severe financial hardship due to the COVID-19 pandemic. My primary place
of employment is/was closed due to the Governor’s Executive Order 20-07 or 20-12, or my
income has substantially decreased due to the Governor’s Executive orders 20-07 or 20-12.
(Note to applicant: see pages 4-5 for details of Executive Order 20-07 or 20-12.)
2
If yes to the question above, please describe the following:
SECTION TWO: PLEASE REFER TO EACH QUESTION BELOW TO DETERMINE YOUR ELIGIBILITY.
YES NO
I applied for unemployment insurance or the pandemic unemployment assistance program
(PUA).
If you answered “NO” to this question, you are still eligible for the program subject to the availability of
funds, please continue to section three.
If you answered “YES” to this question, please answer the question below.
My unemployment insurance or pandemic unemployment assistance payments are current.
If you answered “NO”, you are eligible for the program subject to the availability of funds, ple
ase continue to
section three.
If you answered “YES” to this question, then you are not eligible for this program.
Name of Business or Employer:
Type of Employment (restaurant, personal services, for-hire transportation services, etc.):
Description of Financial Impact (date of closure, description of reduced operations and impact on your
employment, or how COVID-19 has otherwise substantially affected your income):
Note: your state unemployment assistance payments are considered current if you have received payments for all
weeks claimed, or all weeks claimed except for the most recently claimed week. For example: if you claimed weeks
3/27/20 through 8/02/20, you are considered current if you received all payments except for claim week 8/02/20.
Please note for the purposes of this form, please answer your unemployment status according to your base state
benefit (not additional federal payments) and your answer should not include the "waiting week".
YES NO
3
SECTION THREE: ALL APPLICANTS MUST COMPLETE.
YES NO
I understand that providing inaccurate information will be considered providing a false
statement and may subject me to full repayment of any funds distributed through this
program.
OPTIONAL: WHAT IS YOUR RACE OR ETHNIC ORIGIN? MARK AS MANY BOXES AS APPLY.
☐
African
☐
Native American or Alaska Native
☐
Asian
☐
Native Hawaiian or Pacific Islander
☐
Black/African American
☐
Slavic
☐
Latino/Hispanic
☐
White
☐
Middle Eastern
☐
Decline to answer.
SECTION FOUR: ALL APPLICANTS MUST COMPLETE.
___________________________________________________ __________________________________
Applicant Name (First/Last/M) Date
___________________________________________________ __________________________________
Applicant Signature (may be electronic) Birthdate
__________________________________
Phone Number (optional)
__________________________________________________________________________________________
Home Address
__________________________________________________________________________________________
Mailing Address (if different)
4
SECTION FIVE: MUST BE COMPLETED BY FINANCIAL INSTITUTION.
____________________________________________ _____________________________________
Type of ID and ID Number Provided by Applicant Applicant No.: (from query portal: XX,XXX)
__________________________________________________________________________________________
Employee Name / Name of Participating Financial Institution / Branch ID
FAQ: HOW DO I KNOW IF MY INCOME HAS BEEN IMPACTED BY COVID-19?
The Governor issued executive orders 20-07 and 20-12 to reduce the spread of COVID-19 in Oregon and to
save lives. If your personal income has been significantly affected by these orders, you may be eligible for
relief funds. Please note: there is a limited amount of funding available through this program. If you are not
significantly impacted by COVID-19 please consider pursuing other types of financial relief and allowing those
most in need to access this program.
The Governor’s Executive Order 20-12 closed “Amusement parks; aquariums; arcades; art galleries (to the
extent that they are open without appointment); barber shops and hair salons; bowling alleys; cosmetic
stores; dance studios; esthetician practices; fraternal organization facilities; furniture stores; gyms and fitness
studios (including climbing gyms); hookah bars; indoor and outdoor malls (i.e., all portions of a retail complex
containing stores and restaurants in a single area); indoor party places (including jumping gyms and laser tag);
jewelry shops and boutiques (unless they provide goods exclusively through pick-up or delivery service);
medical spas, facial spas, day spas, and non-medical massage therapy services; museums; nail and tanning
salons; non-tribal card rooms; skating rinks; senior activity centers; ski resorts; social and private clubs;
tattoo/piercing parlors; tennis clubs; theaters; yoga studios; and youth clubs.“
Governor’s Executive Order 20-07 may have temporarily closed businesses such as “restaurants, bars, taverns,
brew pubs, wine bars, cafes, food courts, coffee shops, clubs, or other similar establishments that were
prohibited to offer food or drink on-premises” or significantly reduced their hours of operation.
Additional services such as app-based peer-to-peer services, transportation employers such as cab companies,
and other types of employment may have been indirectly affected by the Governor’s orders. If your type or
place of employment is not listed above, please describe your COVID-19 related income impact in the
attached form. Describing how COVID-19 has severely reduced your income will satisfy this requirement.
5
FAQ: WHAT DOCUMENTS ARE ACCEPTABLE?
PROOF OF IDENTITY – MUST INCLUDE PHOTO AND NOT BE EXPIRED PRIOR TO 03/01/2020
▪ Oregon state issued driver’s license
▪ Oregon state issued ID card
▪ U.S. passport, U.S. passport card or U.S. Territory passport
▪ Military ID
▪ Resident alien card
▪ A tribal ID card issued by one of the following:
o The Confederated Tribes of Warm Springs Reservation of Oregon
o Confederated Tribes of Siletz Indians Tribal Identification Card
o Confederated Tribes of Umatilla Indian Reservation
o Burns Paiute Reservation
o Cow Creek Band of Umpqua Indians
o Official Tribal Identification of the Klamath Tribes
o Confederated Tribes of Grand Ronde Oregon
o Confederated Tribes of Coos, Lower Umpqua & Siuslaw Indians
o Coquille Indian Tribe Enrollment Identification Card
PROOF OF IN-STATE RESIDENCY (IF THE DOCUMENT USED FOR PROOF OF IDENTITY DOES NOT
INCLUDE A CURRENT ADDRESS OR IS EXPIRED):
▪ Current Oregon vehicle title or registration card
▪ Utility hook up order or utility statement issued by the service provider*
▪ Any document issued by a financial institution that includes your residence address*
▪ Any communication or document by a state, local, or federal government entity
▪ Any document issued by an insurance company or agent*
▪ Any document issued by an educational institution*
▪ Current Rental/Lease Agreement that includes the original signature of the lessor or landlord
▪ Paycheck, paystub, W-2 or 1099 tax form*
*Document must be current as demonstrated by the date of correspondence (within 45 days of date of
application)
IF YOUR LEGAL NAME IS DIFFERENT THAN YOUR PRIMARY PROOF OF IDENTITY:
▪ An official government issued marriage certificate/license
▪ A record of Domestic Partnership issued by Oregon Vital Statistics
▪ An out-of-state government issued record of Domestic Partnership
▪ A U.S. city, county or state court-issued divorce decree, judgment of dissolution of marriage,
annulment of marriage decree, judgment of dissolution of domestic partnership, or annulment
of domestic partnership
▪ A government-issued death certificate of spouse which includes a connection to your current
full legal name
▪ An adoption decree or court decree, order or judgment legally changing the applicant's name
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OREGON EMERGENCY COVID-19 RELIEF PROGRAM (City of Oakland)

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Completed 30 April 2021

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