Nez Perce Tribe Financial Assistance Application

The Nez Perce Tribe Financial Assistance Program is for Nez Perce enrolled members ages 18 and older.

Federal Poverty Guidelines shall be applied

All verifications are required with each application

INCOMPLETE applications will be denied

Nez Perce tribal members are allowed one grant per fiscal year

Checks and Purchase orders will be processed within 10 business days

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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

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* 3. Nez Perce Enrollment #

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* 4. Birthdate:

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* 5. Age:

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* 6. Gender:

Male

Female

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* 7. How much total combined money do all members of your HOUSEHOLD earn? This includes money from jobs; net income from business, farm, or rent; pensions; dividends; interest; social security payments; and any other money income received by members of your HOUSEHOLD that are EIGHTEEN (18) years of age or older. Please report the total amount of money earned - do not subtract the amount you paid in taxes or any deductions listed on your tax return.

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* 8. Are you Employed?

Yes

If Yes, List Employer:

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* 9. How have you been affected by COVID-19

Increased Utility Expenses

Increased Grocery

Loss of Income

Cleaning/Sanitation Expense

Medical Expense

Rent/Mortgage

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* 10. I Wish to Apply for:

$150 (Financial Assistance) 18-61

$500 (Elder Assistance) 62 and older

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* 11. Reason For Request:

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* 12. Name of Vendor:

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* 13. If you would like Direct Deposit Please fill out this portion:

Bank

Routing Number

Account Number

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* 14. Are you Homeless?

Yes

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* 15. Are you a Veteran?

Yes

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* 16. I understand Financial Assistance/Elder Assistance is available once per fiscal year. There is not a a separate program or additional funds for COVID-19.

Yes

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* 17. Tribal ID

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

Choose File

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* 18. Income Verification

Upload Income Verification

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

Choose File

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* 19. Document of Need (Invoice, Bill)

Upload the bill or invoice you need assistance with

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

Choose File

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* 20. For Office Use Only Finance Requisition
Recommend : Approved or DENY Initials:_ Date:__
Purchase Order:_ Check: Direct Deposit:
Vendor#:_____
Vendor:
Amount:
Accountant Initials:
1237-53-7700

Originating Employee:
Immediate Supervisor:
Account # If needed:

Nez Perce Tribe Financial Assistance Application

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

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* 3. Nez Perce Enrollment #

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* 4. Birthdate:

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* 5. Age:

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* 6. Gender:

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* 8. Are you Employed?

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* 9. How have you been affected by COVID-19

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* 10. I Wish to Apply for:

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* 11. Reason For Request:

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* 12. Name of Vendor:

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* 13. If you would like Direct Deposit Please fill out this portion:

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* 14. Are you Homeless?

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* 15. Are you a Veteran?

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* 16. I understand Financial Assistance/Elder Assistance is available once per fiscal year. There is not a a separate program or additional funds for COVID-19.

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* 17. Tribal ID

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* 18. Income Verification

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* 19. Document of Need (Invoice, Bill)

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* 20. For Office Use Only Finance RequisitionRecommend : Approved or DENY Initials:_________ Date:______________Purchase Order:_______ Check:__________ Direct Deposit:Vendor#:_____________Vendor:Amount:Accountant Initials:1237-53-7700Originating Employee:Immediate Supervisor:Account # If needed:

* 20. For Office Use Only Finance Requisition
Recommend : Approved or DENY Initials:_ Date:__
Purchase Order:_ Check: Direct Deposit:
Vendor#:_____
Vendor:
Amount:
Accountant Initials:
1237-53-7700

Originating Employee:
Immediate Supervisor:
Account # If needed: