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Tlingit and Haida Indian Tribes of Alaska 2020 (Central Council Tlingit and Haida Indian Tribes of Alaska)

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U.S.A. forms for Central Council Tlingit and Haida Indian Tribes of Alaska

BROWSE CENTRAL COUNCIL TLINGIT AND HAIDA INDIAN TRIBES OF ALASKA (AK) FORMS

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Page 1 of 6
CENTRAL COUNCIL
Tlingit and Haida Indian Tribes of Alaska
CARES Act Financial Assistance Program • Edward K. Thomas Building
9097 Glacier Highway; Juneau, Alaska 99801
Phone: 907.463-7788 • Fax: 1.888.493.5169 • Email: caresrelief@ccthita-nsn.gov
2020 CARES Act Financial Assistance
Tlingit & Haida is pleased to offer two Coronavirus Aid, Relief, and Economic Security (CARES) Act need-
based programs for tribal citizen households impacted by the Coronavirus 2019 (COVID-19) pandemic.
Tribal citizens are eligible to apply for both programs with this application. Grants are awarded on a per
household basis. Note: This support is not a per-capita distribution.
Family Education & Retraining Program Family Home & Utility Program
This is a one-time, needs-based program that will
provide up to $500 per household to tribal citizens
with unexpected education and related expenses
due to the COVID-19 pandemic. The program
was established to offset education related
expenses.
Eligible Expenses:
• The cost of hardware to participate in
distance education (e.g. a laptop, a camera,
a microphone, etc.)
• Increased costs for internet due to
education
• Cost of tuition if you are seeking education
to change your employment options due to
COVID-19.
Who Can Apply:
• All tribal citizens, regardless of where they
reside, are eligible to apply to receive
support from this program.
Eligibility Requirements:
• Must be a U.S. Citizen
• Must be enrolled with Tlingit & Haida
• Must demonstrate financial hardship that
directly relates to COVID-19
This is a one-time, needs-based program that will
provide up to $500 per household to tribal citizens
with unexpected reductions in income and increased
family expenses due to the COVID-19 pandemic.
The program was established to offset housing
related expenses.
Eligible Expenses:
• Mortgage
• Rent
• Utilities
Who Can Apply:
• All tribal citizens, regardless of where they
reside, are eligible to apply to receive support
from this program.
Eligibility Requirements:
• Must be a U.S. Citizen
• Must be enrolled with Tlingit & Haida
• Must demonstrate financial hardship that
directly relates to COVID-19
Applicants must include documentation of expenses (e.g. receipts, lease agreement, etc.) for each grant for
expenses paid between April 1 to December 31. Financial assistance is awarded for expenses that
have already been paid and is not for forecasted or anticipated expenses.
Page 2 of 6
2020 CARES Act Financial Assistance Instructions
Please follow the written instructions for each section. Incomplete applications will be denied.
Section 1 – Applicant Information
• Provide tribal citizens name and any previous names used.
• You or another household member must be enrolled with Tlingit & Haida in order to be eligible.
• Provide tribal citizens Social Security number.
• Provide tribal citizens date of birth.
• Provide YOUR name if different from tribal citizen.
• Provide current mailing address for tribal citizen.
• Provide the physical household address of the tribal citizen.
• Provide YOUR phone number where an eligibility technician can reach you.
• Provide YOUR email address where an eligibility technician can reach you.
• List all individuals living in the household.
Section 2 – Educational Costs
• Check the box if you are applying for the Family Education & Retraining program assistance.
• You MUST provide proof of costs.
• Include dated receipt for education related hardware, internet, or tuition.
• Costs must be incurred between April 1, 2020 and December 30, 2020.
Section 3 – Housing Costs
• Check the box if you are applying for the Family Home & Utility program assistance.
• If you check “Other”, please provide an explanation.
• You MUST provide proof of costs.
• Include rental lease outlining your monthly rent or a mortgage statement.
• If you do not have a lease or mortgage statement, you may provide a utility bill (e.g. electric, oil, etc.).
•
Costs must be incurred between April 1, 2020 and December 30, 2020.
Section 4 – Client Set Up – Needed for Payment
• This form must be completed.
• Choose “New” if this is the first time you have completed this form, otherwise chose “Update”.
• Complete all personal information.
• Choose “Client” under the Non-Taxable Vendor column.
• Sign and date the form.
Section 5– Paper Check or Direct Deposit Electronic Funds Transfer Request
• Choose “Paper Check Request” if you would like a check mailed to you.
• Choose “Direct Deposit - Electronic Funds Transfer Request” if you would like the payment to be
deposited into your bank account.
• Attach account verification.
Section 6– Certifications
• Check or initial each box and sign the bottom of the page.
How to Submit Your Application:
Email to:
caresrelief@ccthita-nsn.gov
Mail to:
Tlingit & Haida CARES Relief
9097 Glacier Hwy. Juneau, AK 99801
Fax to:
1.888.493.5169
Page 3 of 6
2020 CARES Act Financial Assistance Application
SECTION 1 – Applicant Information
Full Name: _______________________________Maiden Name if Applicable ________________________
Enrollment No.: ________________________ Date of Birth: ____________________________________
Household Information (List all individuals, tribal citizens and non-tribal citizens, living in your household).
Name: ___________________________________ Relationship/Age: _____________________________
Name: ___________________________________ Relationship/Age: _____________________________
Name: ___________________________________ Relationship/Age: _____________________________
Name: ___________________________________ Relationship/Age: _____________________________
Name: ___________________________________ Relationship/Age: _____________________________
SECTION 2 – EDUCATIONAL COSTS (Skip to Section 3 if you are not selecting this option).
I certify that I have been financially impacted by COVID-19 by:
Expending at least $500 for the cost of the education related hardware;
Increased internet costs of at least $500 incurred between April 1, 2020 and December 30, 2020;
Tuition costs of at least $500 incurred because I am seeking education to change my employment
options due to COVID-19.
Proof of costs MUST be attached to this application (e.g. receipt for computer, internet bill, etc ).
SECTION 3 – HOUSING COSTS (Skip to section 4 if you are not selecting this option).
I certify that I have been financially impacted by COVID-19 and that as a result of the financial
impacts above my household needs at least $500 for mortgage, rent, or utilities costs that
incurred between April 1, 2020 and December 30, 2020.
I was financially impacted by COVID-19 due to:
Job Loss
Decreased Work Hours
Other (Specify):
Furlough
Increased Childcare Costs
Proof of costs MUST be attached to this application (e.g. a lease, mortgage statement or utility bill).
Page 4 of 6
SECTION 4 – Client Set Up – NEEDED FOR PAYMENT
Request for Client Setup
(This form is used in lieu of the W9 form published by the Internal Revenue service)
All required forms must be completed and signed before payment is issued
Legal Name (as shown on your tax return)
Social Security Number
Mailing Address:
City: State: Zip:
Telephone Number:
( )
Physical Address:
City: State: Zip:
Email Address:
Certification:
Under penalties of perjury, I certify that:
1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to
me and
2) I am not subject to backup withholding because: (a) I am exempt from backup withholding; or (b) I have not been notified
by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or
dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding and
3) I am a US person (including a US Resident alien)
Certification instructions: You must cross out 2 above if you have been notified by the IRS that you are currently subject to
backup withholding because you have failed to report all interest and dividends on your tax return.
Signature Date
Penalties
Failure to furnish TIN: If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50.00 for each
such failure unless your failure is due to a reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding: If you make a false statement with no reasonable basis that
results in no backup withholding, you are subject to a $500.00 penalty.
Criminal penalty for falsifying information: Willfully falsifying certifications or affirmations may subject you to criminal
penalties including fines and/or imprisonment.
Misuse of TINs: If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and
criminal penalties.
Finance Only
Debarment Certification:
Date
☐
New
☐
Update
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signature
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Page 5 of 6
SECTION 5 – Paper Check or Direct Deposit Electronic Funds Transfer Request
Paper Check Request
I am requesting a paper check be mailed to me for the CARES funds that are awarded to me.
OR
Direct Deposit – Electronic Funds Transfer Request
I am requesting direct deposit.
I hereby authorize Tlingit & Haida to initiate direct deposits to my account at the financial institution named
below. I also authorize Tlingit & Haida to make withdrawals from this account in the event that a credit entry is
made in
error.
Further, I agree NOT to hold Tlingit & Haida responsible for any delay or loss of funds due to incorrect or
incomplete information supplied by me or by my financial institution or due to an error on the part of my
financial institution in depositing funds to my account. This agreement will remain in effect until Tlingit &
Haida receives a written notice of cancellation from me or my financial institution, or until I submit a new
direct deposit form to the Finance Department.
Name and Address (Please Print)
(
new address)
For verification purposes please
provide your Social Security
Number:
Phone Number:
Email Address:
Name of Financial Institution:
Financial Institute Phone Number:
Your Account Number
Checking or
Savings
Transit Routing Number
Signature Date
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signature
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Page 6 of 6
SECTION 6 – CERTIFICATIONS (Check or initial each box, sign and date where indicated).
I certify that I am a United States citizen
I certify that I am submitting this form to Tlingit & Haida to request relief from financial
impacts caused by the COVID-19 pandemic on behalf of my household.
I certify that I will notify Tlingit & Haida if my costs change and allow Tlingit & Haida to
reevaluate my application.
I acknowledge that these one-time funds may impact other assistance programs as it may be
counted as unearned income.
By signing below, I affirm everything documented on or attached to this form is true and accurate.
Signature Date
Printed Name: _____________________________
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Tlingit and Haida Indian Tribes of Alaska 2020 (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Completed 26 January 2021

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