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

Question Title

* 1. CERTIFICATION FOR CORONAVIRUS ECONOMIC RELIEF PAYMENT

Question Title

* 2. Tolowa Enrolled Child
(Type Name)

Question Title

* 3. Additional Tolowa Enrolled Child
(Type Name)

Question Title

* 4. Additional Tolowa Enrolled Child
(Type Name)

Question Title

* 5. Additional Tolowa Enrolled Child

Question Title

* 6. Additional Tolowa Enrolled Child 

Question Title

* 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.

0 of 7 answered
 

T