COVID-19 ADULT ASSISTANCE PROGRAM FORM

The Tolowa Dee-ni’ Nation (Nation) is committed to providing assistance to eligible individuals who have been negatively impacted by the COVID-19 pandemic. The Nation will provide targeted relief payments to those who certify that they have experienced physical or financial hardship due to this public health crisis. The means and amount of this assistance will be determined by the Nation. Those wishing to receive assistance must fill out the following form to receive assistance.

Question Title

* 1. CERTIFICATION FOR CORONAVIRUS ECONOMIC RELIEF PAYMENT

NAME:

ADDRESS:

CITY:

STATE:

ZIP CODE:

PHONE:

DATE OF BIRTH:

TRIBAL ID #:

EMAIL, IF AVAILABLE:

Question Title

* 2. CERTIFICATION OF NEED:

I, the undersigned, certify that I have been physically or financially impacted by the COVID-19 pandemic and am in need of coronavirus relief assistance. By accepting such assistance, I confirm that this statement is true and correct, andd that I will not challenge the means, method, or amount of any assistance I might receive from the Nation in its sole discretion.

Signature (type full name)

Date