COVID-19 CHILD 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.

NOTE TO PARENTS: COMPLETE THIS CHILD FORM TO RECEIVE ASSISTANCE FOR CHILDREN ONLY; YOU MUST COMPLETE THE SEPARATE ADULT FORM TO RECEIVE ASSISTANCE FOR YOURSELF, AS AN ADULT CITIZEN. Shu’ shaa nin-la

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* 1. CERTIFICATION FOR CORONAVIRUS ECONOMIC RELIEF PAYMENT

NAME (of LEGAL GUARDIAN):

ADDRESS:

CITY:

STATE:

ZIP CODE:

PHONE:

DATE OF BIRTH:

TRIBAL ID #:

EMAIL, IF AVAILABLE:

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* 2. Tolowa Enrolled Child
(Type Name)

Child One Name

Child One Tribal ID#

Child One Date of Birth

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* 3. Additional Tolowa Enrolled Child
(Type Name)

Child Two Name

Child Two Tribal ID#

Child Two Date of Birth

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* 4. Additional Tolowa Enrolled Child
(Type Name)

Child Three Name

Child Three Tribal ID#

Child Three Date of Birth

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* 5. Additional Tolowa Enrolled Child

Child Four Name

Child Four Tribal ID#

Child Four Date of Birth

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* 6. Additional Tolowa Enrolled Child

Child Five Name

Child Five Tribal ID#

Child Five Date of Birth

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* 7. DECLARATION:
I certify that I am the legal guardian of the named children and they reside in my household.

CERTIFICATION OF NEED:
I, the undersigned, certify that I & my household 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, and that I will not challenge the means, method, or amount of any assistance I might receive from the Nation in its sole discretion.

Signature

Date

COVID-19 CHILD ASSISTANCE PROGRAM FORM

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* 1. CERTIFICATION FOR CORONAVIRUS ECONOMIC RELIEF PAYMENT

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* 2. Tolowa Enrolled Child(Type Name)

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* 3. Additional Tolowa Enrolled Child(Type Name)

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* 4. Additional Tolowa Enrolled Child(Type Name)

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* 5. Additional Tolowa Enrolled Child

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* 6. Additional Tolowa Enrolled Child

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* 2. Tolowa Enrolled Child
(Type Name)

* 3. Additional Tolowa Enrolled Child
(Type Name)

* 4. Additional Tolowa Enrolled Child
(Type Name)