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POKAGON BAND OF POTAWATOMI INDIANS COVID-19 EMERGENCY ASSISTANCE (Pokagon Band of Potawatomi Indians)

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1
Application for COVID-19 Emergency Assistance
POKAGON BAND OF POTAWATOMI INDIANS
COVID-19 EMERGENCY ASSISTANCE PROGRAM APPLICATION
GENERAL DESCRIPTION
• C
ompleted Applications must be delivered to the Band’s Department of Social Services located at: 58620 Sink Road
,
D
owagiac, Michigan 49047, or by Email Social.Services@PokagonBand-nsn.gov, or by Fax 269-782-4295. N
o
a
pplications will be accepted after 5:00 pm on December 10, 2020.
• C
OVID-19 Emergency Assistance Program is governed by the COVID-19 Emergency Assistance Program Policy
(“Policy”), copies of which are available at the Department of Social Services. The Policy shall control in the event of
any conflict with this Application.
• An Ap
plicant must: (1) be a Band Citizen or Non-Citizen Parent; (2) be at least 18 years of age; (3) have Increased
Need or Job Loss Related Need; (4) have an adjusted gross income for 2019 that does not exceed, or have suffered an
income reduction in 2020, and it is Highly Unlikely that the person will have an adjusted gross income for 2020 that
does not exceed: (i) $75,000 for Applicants who filed their 2019 federal income tax returns under “single” status, or ar
e
H
ighly Likely to file their 2020 federal income tax return under such status, as applicable; (ii) $112,500 for Applicants
who filed their 2019 federal tax returns under “head of household” status, or are Highly Unlikely to file their 2020
federal income tax return under such status, as applicable; or (iii) $150,000 for Applicants who filed their 2019 federal
tax returns under “married filing jointly” status, or are Highly Likely to file their 2020 federal income tax return under
such status, as applicable; and (5) complete and return to the Department this application, along with all required
documentation, including as set forth in the Policy, Exhibit A Schedule of Acceptable Documents.
• A
ssistance is limited and subject to available funding, not to exceed $1,500 per month, per household for either
Increased Need or Job Loss Related Need
.
o “Increased Need” means financial need arising from increased costs related to the Emergency, including without
limitation, food, childcare, medical care, home office, cleaning supplies, personal protection equipment and
e
ducation (such as having to purchase a laptop for remote learning) and funeral expenses. Increased Need does not
and is not intended to replace funding under any Band program negatively impacted by the Emergency, including
but not limited to the HEAP
.
o “Job Loss Related Need” means financial need arising from employment interruption, job loss or reduced
income, including without limitation, difficulty in making mortgage or rent payments, utility payments, purchasing
food, and paying for medical care, making car payments, paying for insurance and similar living expenses, all as a
result of the Emergency.
• An Applicant may apply for Assistance for both Increased Need and Job Loss Related Need in the same month, but
Assistance will not be awarded for both Increased Need and Job Loss Related Need in the same month, rather for each
month, the Department will award the higher amount for which the Applicant is eligible. For example, if for the same
2
Application for COVID-19 Emergency Assistance
mon
th, an Applicant applies for Increased Need in the amount of $500 and Job Loss Related Need of $1,500, any award
would be limited to $1,500.
• Assi
stance shall only be provided for the period of August 1, 2020 through December 10, 2020, and Assistance shall
not be provided for amounts accrued prior to August 1, 2020.
• As
sistance shall not be used for or include expenses that have been or will be reimbursed under any federal program or
any other Band program, or for damages covered by insurance.
• Appl
icants must have and retain a copy of all evidence submitted to the Department in support of Increased Need and/or
Job Loss Related Need, as applicable, and must provide the same to the Department upon request.
3
ASSISTANCE
I am applying for Assistance for the month of (mark only one):
□ August 2020 □ September 2020 □ October 2020 □ November 2020 □ December 1-10, 2020
You may apply for Assistance for both Increased Need and Job Loss Related Need in the same month, but Assistance will
not be awarded for both Increased Need and Job Loss Related Need, rather for each month, the Department will award the
higher amount for which you are eligible. An Applicant who seeks Assistance for another month, must reapply.
Increased Need:
□ I have incurred “Increased Need” (see page 1 for meaning) for the above month in the total amount of $__________
(this total must match the itemized total in below table)
Briefly Describe Increased Need
Amount of Increased Need
Itemized Total
Job Loss Related Need:
□ I have incurred “Job Loss Related Need” (see page 1 for meaning) for the above month in the total amount of
$__________ (this total must match the itemized total in below table)
Briefly Describe Job Loss Related Need
Amount of Job Loss Related Need
Itemized Total
Application for COVID-19 Emergency Assistance
4
Application for COVID-19 Emergency Assistance
Name __________________________________________ Date ___________________________________
Telephone No. __________________
_________________ Date of Birth ____________________________
Band Enrollment N
umber __________________________ SSN___________________________________
Physical Address
____________________________________________________________________________________
Mailing Address (
if different) __________________________________________________________________________
□ Rent □ Own
Email _______________________________________
___ Fax ___________________________________
Minor’s Name ___________________________________
(If Applicant is Non-Citizen Parent)
HOUSEHOLD
List all pers
ons (including name, date of birth, social security number, and enrollment number) who reside at the above
principal residence.
Name
Date of Birth
Social Security Number
Enrollment Number
APPLICANT
Minor's Enrollment Number
______________
(If Applicant is Non-Citizen Parent)
Are you a Tribal Citizen?
Yes No
5
Application for COVID-19 Emergency Assistance
ADJ
USTED GROSS INCOME
Complete the information below under either 2019 Adjusted Gross Income or 2020 Adjusted Gross Income.
2019 Adjusted Gross Income
Mark the applicable box below if you are eligible for Assistance based on your 2019 adjusted gross income.
M
y adjusted gross income for 2019 was $___________, and such amount does not exceed:
□ $75,000 and I filed my 2019 federal income tax return under “single” status
□ $112,500 and I filed my 2019 federal income tax return under “head of household” status
□ $150,000 and I filed my 2019 federal income tax return under “married filing jointly” status
□ I did not file a 2019 federal income tax return
2020 Adjusted Gross Income
Mark the applicable box below if you are not eligible for Assistance based on your 2019 adjusted gross income, and you
have suffered a job loss or income reduction in 2020 and are Highly Likely to have adjusted income for 2020 that does not
exceed:
□ $75,000 and it is Highly Likely that I will file my 2020 federal income tax return under “single” status
□ $112,500 and it is Highly Likely that I will file my 2020 federal income tax return under “head of household” status
□ $150,000 and it is Highly Likely that I will file my 2020 federal income tax return under “married filing jointly” status
□ It is Highly Likely that I will not file a 2020 federal income tax return, and that my 2020 adjusted gross income will be
$___________.
I
n 2019, my adjusted gross income was $____________.
I
n 2019, if I filed a 2019 federal income tax return, it was filed under the following status:
□ Single □ Head of Household □ Married Filing Jointly
“H
ighly Likely” means having a high probability of occurring or being true based on an objective review of relevant facts
and circumstances.
6
Application for COVID-19 Emergency Assistance
CERT
IFICATIONS AND AUTHORIZATIONS
By signing below, the undersigned applicant makes the following representations, authorizations, and certifications:
• I have read the Band’s COVID-19 Emergency Assistance Program Policy in effect at the time this application is
submitted, and I am eligible to receive Assistance under the Policy.
• I attest and certify that to the best of my information, knowledge, and belief all information provided in this application
is true, accurate, and complete.
• I acknowledge and understand that I must retain a copy of all evidence submitted to the Department in support of
Increased Need and/or Job Loss Related Need, as applicable, and must provide the same to the Department upon request.
• I acknowledge and understand that Assistance shall not be used for or include expenses that have been or will be
reimbursed under any federal program or any other Band program.
• I acknowledge and understand that if I am a Band Citizen, then although the Band has structured the Program with the
intent that the Assistance be non-taxable, if the IRS deems the Assistance, or any part of the Assistance, to be taxable,
then I (and not the Band) shall be solely responsible for any taxes, interest and penalties owed from my receipt of any
Assistance.
• I acknowledge and understand that if I am a Non-Citizen Parent, the Band will treat the Assistance as taxable and I (and
not the Band) shall be solely responsible for any taxes, interest and penalties owed from my receipt of any Assistance.
• I acknowledge and understand that providing any false information may subject me to legal action, including without
limitation, criminal prosecution.
_______________
__________________________ _______________________________________
Applicant’s Signature Print Applicant’s Name
Date: ____________________________________
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POKAGON BAND OF POTAWATOMI INDIANS COVID-19 EMERGENCY ASSISTANCE (Pokagon Band of Potawatomi Indians)

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Completed 12 August 2020

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