CLPVC Tribal Member - Direct Payment Assistance - Minor & POA

Application deadline: 9/30/2022

Clarks Point Village Council is providing all CLPVC tribal members who have been negatively impacted by the COVID-19 pandemic with a direct payment of $1,123.56 to help offset the financial hardships caused by the COVID-19 pandemic and increased living costs due to current world events. Applications will be processed in the order they were received.

*This application can be used to submit a single application for your CLPVC tribally enrolled minor children and those for whom you are the legal power of attorney (if applicable).

Question Title

* 1. Legal Guardian/Parent or Power of Attorney Contact Information

Full Legal Name

Date of Birth

CLPVC Tribal # (If known)

Mailing Address (including City/State/Zip)

Phone Number

Email (optional)

Question Title

* 2. Program Options *Disclaimer, cash assistance in any amount may affect those who receive public/government assistance. CLPVC strongly encourages any tribal member who receives assistance through another program to verify if a direct payment could negatively impact them.

Direct Payment of $1123.56 to parent/legal guardian/POA.

Direct Payment to a vendor instead.

Question Title

* 3. I understand that this program is for CLPVC tribal members who have been negatively economically impacted by the COVID-19 pandemic and have experiencing increased living costs due to COVID-19 and current world events. I also understand that payments will be issued via check and that it may take up to 30 days for a completed application to be processed. I also understand if I opt for a vendor payment instead of a direct payment, that CLPVC reserves the right to decline a vendor payment if the vendor does not meet the intention of the funding (liquor stores, gambling...etc.). It the responsibility of the applicant to contact the vendor ensure they'll accept the payment.

Yes

Question Title

* 4. Additional Information. Please use this section if you have additional application information you would like to share with CLPVC. (If you elected for a vendor payment instead of a direct payment, please provide the vendor's name, address, and your account # here).

Question Title

* 5. If you are the legal guardian/parent for a CLPVC tribally enrolled minor(s) provide their name and date of birth below.

#1 Minor's Full Name

#1 Minor's Date of Birth

#2 Minor's Full Name

#2 Minor's Date of Birth

#3 Minor's Full Name

#3 Minor's Date of Birth

#4 Minor's Full Name

#4 Minor's Date of Birth

#5 Minor's Full Name

#5 Minor's Date of Birth

Question Title

* 6. If you are the legal Power of Attorney for a CLPVC tribally enrolled adult please provide their name and date of birth below.

Name of Adult protected by POA

Adult's Date of Birth

Question Title

* 7. I certify that I am legally authorized to submit an application on behalf of the CLPVC tribally enrolled child/children as their parent/legal guardian or on behalf of an adult as their legal Power of Attorney as listed above. I also certify on their behalf that they have been negatively impacted by the COVID-19 Pandemic and current world events and that I understand that providing incorrect information could subject me to recoupment to funds and other lawful penalties. I certify that the information above is true and correct to the best of my abilities. I understand that documentation may be required for POA or when applicable in instances of legal guardianship.

Name

Date