1. ARP Individual Assistance (Adult)

Name, Enrollment and Contact Information
On 09/29/2021, the Business Committee of the Ottawa Tribe of Oklahoma authorized an individual assistance program using American Rescue Plan Coronavirus State & Local Fiscal Recovery Program (CSLFRP) Funds in response to the COVID 19 public health emergency and its lasting negative economic impacts.  The program offers direct monetary assistance to Ottawa tribal members living in households that have experienced direct negative economic impacts from COVID 19.  Program funds will award up to $2,000 to each eligible tribal member.  Applications will remain open until April 29, 2022.

The Department of Treasury's Interim Final Rule governing the use of CSLFRP funds sets forth that the Tribe "may presume that a household or population that experienced unemployment or increased food or housing insecurity or is low- or moderate-income experienced negative economic impacts resulting from the pandemic."  This survey is designed to allow the Tribe to determine the applicant tribal member's eligibility on those terms.  For this purpose, taking guidance from the federal government's own direct payment program under the American Rescue Plan, the Ottawa Tribe of Oklahoma is defining "moderate income" as being an annual income (Adjusted Gross Income or AGI on federal tax forms) of $75,000 or less for a single filer, $112,500 or less for a head of household filer or $150,000 or less for married filing jointly.

Tribal members who do not meet the eligibility requirements may still qualify for assistance based on demonstration of direct negative impact from the COVID 19 emergency.

Question Title

* 1. Tribal Member Name

Question Title

* 2. Enrollment Number

Question Title

* 3. Date of Birth

Date

Question Title

* 4. Are you the above listed person?

Question Title

* 5. Mailing Address

Question Title

* 6. Tribal Member Telephone 1 (Daytime Hours Central Time)

Question Title

* 7. Tribal Member Telephone 2 (Alternate If Necessary)

Question Title

* 8. Tribal Member E-Mail

Question Title

* 9. Is this tribal member the legal guardian of one or more minor tribal members who will also be applying for ARP economic assistance? (note that this uses a different survey form)

Question Title

* 10. If you are filing on behalf of a Tribal Member (see Question 4) please provide your name and contact information as well

T