Nez Perce Tribe Emergency Medical or Burial Assistance

The Nez Perce Tribe Emergency Financial Assistance is for Nez Perce enrolled members ages 18 and older that need travel assistance for Extreme medical transportation or Burial transportation.

*18 and older, we do not offer assistance for minors

*Proof of emergency from hospital (Can provide a phone number for our office to make contact)

*Extreme Emergency Medical assistance can assist to see immediate family at risk of life or limb that are at least 45 miles in distance 1 way

*Burial Travel Assistance is to attend the burial of immediate family when travel is at least 45 miles or more 1 way

*Assistance is limited to 1 per household

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* 1. CERTIFICATION: I fully understand that Title 18, Section 1001 of the United States Code, states that a person is guilty of felony by knowingly and willingly making false or fraudulent statements to any department or agency of the United States. I, therefore, certify the foregoing information is true and complete to the best of my knowledge. I authorize inquires to be made to verify this statement is true. Funds or purchase orders received fraudulently or not used for approved purpose will result in applicant’s ineligibility to receive Nez Perce Tribal Financial Assistance for 2 years from the date of last application. Applicant may be required to reimburse the Nez Perce Tribe for the amount of the Financial Assistance grant.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Are you an enrolled member of the Nez Perce Tribe

Yes

If yes, please provide your tribal enrollment number:

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* 3. Birthdate:

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* 4. Age:

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* 5. Destination:

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* 6. How many miles one way to destination?

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* 7. What is the Emergency?

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* 8. What is your relationship to Person?

Biological Parent

Biological Child

Spouse

Biological Sibling

Biological Great Grandparent

Biological Great Grandchild

Legally adopted, parent,sibling,grandparent or relative in the same household

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* 9. Directions for Check pickup:

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* 10. Direct Deposit Information:

Bank

Routing Number

Account Number

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* 11. Are you Homeless?

Yes

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* 12. Are you a Veteran?

Yes

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* 13. Tribal ID

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 14. For Office Use Only:
Recommend: Approve__ Deny_ Initials:_ Date:
Check:_ Direct Deposit:_________
Vendor:
Amount:
Accountant Initials:
Burial 1010 01 7040
Medical 1010 01 7045

Originating Employee:
Immediate Supervisor:

Nez Perce Tribe Emergency Medical or Burial Assistance

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* 2. Are you an enrolled member of the Nez Perce Tribe

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* 3. Birthdate:

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* 4. Age:

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* 5. Destination:

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* 6. How many miles one way to destination?

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* 7. What is the Emergency?

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* 8. What is your relationship to Person?

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* 9. Directions for Check pickup:

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* 10. Direct Deposit Information:

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* 11. Are you Homeless?

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* 12. Are you a Veteran?

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* 13. Tribal ID

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* 14. For Office Use Only:Recommend: Approve____ Deny_____ Initials:___________ Date:______________Check:___________ Direct Deposit:_____________Vendor:Amount:Accountant Initials:Burial 1010 01 7040Medical 1010 01 7045Originating Employee:Immediate Supervisor:

* 14. For Office Use Only:
Recommend: Approve__ Deny_ Initials:_ Date:
Check:_ Direct Deposit:_________
Vendor:
Amount:
Accountant Initials:
Burial 1010 01 7040
Medical 1010 01 7045

Originating Employee:
Immediate Supervisor: