Delaware Nation
2020 CARES General Welfare Assistance Program
P.O. Box 825
Anadarko, OK 73005
405 / 247-2448
Fax: 405 / 247-4806
By the approval of the Delaware Nation Executive Committee, it has been decided that there is a great
need to provide general welfare assistance to Delaware Nation citizens who have been affected by the
COVID-19 Pandemic. This program shall provide assistance through the 2020 CARES Act funding in the
form of a Wal-Mart gift card to purchase groceries, medical supplies/equipment and cleaning supplies.
Assistance shall be limited to one per household as a one time assistance. Assistance shall be $150 for a
household of one, $300 for a household of two, $450 for a household of three and $600 for a household of
four and more. Incomplete applications will not be accepted. Please ensure proof of enrollment of a
Delaware Nation citizen in your household is submitted with application.
(Please check all that apply):
□ Increase cost of groceries due to COVID-19
□ Need of additional medical supplies and/or equipment
□ COVID-19 symptoms resulting in quarantine or social distancing
□ Termination/furlough or a reduction of hours of employment
□ Daycare, School, or any educational institute closure
□ Difficulty in making rental payments, mortgage payments and utility payments
I hereby certify that I have been affected by the COVID-19 Pandemic, including but not limited to the list
above.
Name (Please Print):____________________________________________________________________
Mailing Address (for Gift Card):___________________________________________________________
_____________________________________________________________________________________
Signature:______________________________________________ Date:_____________________
Name of Delaware Nation Citizen in household______________________________________________
Enrollment # ____________
**DO NOT WRITE BELOW THIS LINE**
Date Received:__________________________ Enrollment Verified:__________________________
Approved Amount:______________________ Applicant Name:_____________________________
Household Composition:__________________ Date Assistance Mailed:_______________________
Gift Card #:____________________________ Approved By:_______________________________
Number of family members within household:______________________
Delaware Nation
2020 CARES General Welfare Assistance Program
P.O. Box 825
Anadarko, OK 73005
405 / 247-2448
Fax: 405 / 247-4806
By the approval of the Delaware Nation Executive Committee, it has been decided that there is a great
need to provide general welfare assistance to Delaware Nation citizens who have been affected by the
COVID-19 Pandemic. This program shall provide assistance through the 2020 CARES Act funding in the
form of a Wal-Mart gift card to purchase groceries, medical supplies/equipment and cleaning supplies.
Assistance shall be limited to one per household as a one time assistance. Assistance shall be $150 for a
household of one, $300 for a household of two, $450 for a household of three and $600 for a household of
four and more. Incomplete applications will not be accepted. Please ensure proof of enrollment of a
Delaware Nation citizen in your household is submitted with application.
(Please check all that apply):
□ Increase cost of groceries due to COVID-19
□ Need of additional medical supplies and/or equipment
□ COVID-19 symptoms resulting in quarantine or social distancing
□ Termination/furlough or a reduction of hours of employment
□ Daycare, School, or any educational institute closure
□ Difficulty in making rental payments, mortgage payments and utility payments
I hereby certify that I have been affected by the COVID-19 Pandemic, including but not limited to the list
above.
Name (Please Print):____________________________________________________________________
Mailing Address (for Gift Card):___________________________________________________________
_____________________________________________________________________________________
Signature:______________________________________________ Date:_____________________
Name of Delaware Nation Citizen in household______________________________________________
Enrollment # ____________
**DO NOT WRITE BELOW THIS LINE**
Date Received:__________________________ Enrollment Verified:__________________________
Approved Amount:______________________ Applicant Name:_____________________________
Household Composition:__________________ Date Assistance Mailed:_______________________
Gift Card #:____________________________ Approved By:_______________________________
Number of family members within household:______________________
Physical Address: ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Contact Phone: __________________________________
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