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Shoalwater Bay Tribal Member (Shoalwater Bay indian Tribe)

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  • 17 check-boxes
  • 60 other fields

Country of origin: US
File type: PDF

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1
Shoalwater Bay Tribal Member
COVID-19 Emergency Assistance Application Form
The COVID-19 Assistance Program is designed to provide emergency financial assistance to
enrolled Shoalwater Bay Tribal Members who have experienced economic hardships due to the
effect of the COVID-19 pandemic. Funding of this program is in accordance with the federal
CARES Act Relief Fund and is non-taxable as a Tribal general welfare assistance program and
per IRS Disaster Relief regulations. Please refer to the Tribe’s COVID-19 Assistance Program
for details on eligibility and use of this assistance. The Assistance payment is $4,000 per enrolled
adult (18 years and over) and $2,000 per enrolled youth (17 years and under) to cover the period
March 1, 2020 through December 30, 2020. This Application shall be maintained as a
confidential record of the Shoalwater Bay Tribe and will not be disclosed without the written
consent of the Applicant, except to the extent that disclosure is required pursuant to the CARES
Act.
APPLICATION DEADLINE December 16, 2020 1:00pm PT
DISTRIBUTION starting on or about December 22, 2020
Email Application or Questions to: cares@shoalwaterbay-nsn.gov
PART 1 – APPLICANT INFORMATION
Applicant Name ______________________________________________________________
(Head of Household)
Tribal Enrollment No.__________ Contact Phone No._______________________________
Email _______________________ Mailing Address_________________________________
City_________________________ State ________ Zip Code ____________________
Physical Address _______________________________________ City__________________
(if different than mailing)
State ________________________ Zip Code ___________ Number in Household _______
Tribal members in Household:
NAME
Relation
DOB
Tribal No.
2
NAME
Relation
DOB
Tribal No.
If legal guardian or custodial parent, please provide proof of legal guardianship or custody.
PART 2 – ECONOMIC NEED
Since March 1, 2020, I have experienced the following (check any or all that apply) economic
impacts due to the COVID-19 Pandemic:
Unemployment Reduced employment
Loss of self-employed/business income Increased food costs
Increased utility costs Increased costs for telework
Increased household cleaning costs Increased costs for distance learning
for school
Increased personal care costs, e.g., Increased costs for looking for work
for protective masks and measures
Increased costs for child care Transportation costs for medical
for testing and procedures
Housing costs increase, foreclosure, eviction, Other unanticipated costs due to
rent COVID-19 as described below:
Increased health care costs, unreimbursed ___________________________
prescription, supplements, counseling
Increased costs for isolation or quarantine ___________________________
due to positive test or COVID-19 exposure
Eldercare, increased costs due to COVID-19 ___________________________
3
PART 3 – CERTIFICATION
I certify that I have been directly impacted by the COVID-19 pandemic as checked above and
that I will use any funds I receive from the Tribe’s COVID-19 Assistance Program solely to
address the COVID-19 related expenses identified in Part 2 above. I certify I meet the Tribal
member COVID-19 Assistance Program requirements, and the information contained herein is
true and correct to the best of my knowledge. I agree that if I do not use these funds in
compliance with the Tribe’s COVID-19 Assistance Program, I will repay the funds to the
Shoalwater Bay Tribe.
Applicant Signature ________________________________________ Date ___/___/___
Other Adult Signature ________________________________________ Date ___/___/___
OFFICIAL USE
Date Received _________ Enrollment Verified________________ Date _________
Amount: $______________ Certification Verified _____________ Date _________
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Shoalwater Bay Tribal Member (Shoalwater Bay indian Tribe)

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Completed 27 January 2021

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