CLPVC Tribal Member - Housing/Utility 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 $3,000.00 toward housing (rent/mortgage/deposit) and/or utility costs (fuel/propane/gas/electric). This is a needs based program 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. Payments will be issued via check directly to the vendor.

*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. 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.

Yes

Question Title

* 3. 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

* 4. 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

* 5. Housing Assistance (Complete this section if you are electing to apply some or all of your assistance towards rent/mortgage/deposit). If you live in a household where you are not on the lease/mortgage, please provide the name of the person on the account for reference and the account #. *If you rent from a private landlord and wish to make a payment directly to your landlord you must provide a copy of your lease/rental agreement letter.

Vendor Name

Mailing Address

Rent or Mortgage?

Account # if Applicable

Name on Account

Amount

Question Title

* 6. Utility Assistance 1 (Complete this section if you are electing to apply some or all of your assistance towards fuel/gas/propane/electricity).

Vendor Name

Mailing Address

Heating or Electric?

Account #

Name on Account

Amount

Question Title

* 7. Utility Assistance 2 (Complete this section if you are electing to apply some or all of your assistance towards fuel/gas/propane/electricity).

Vendor Name

Mailing Address

Heating or Electric?

Account #

Name on Account

Amount

Question Title

* 8. 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 also certify that the assistance above will be applied to the residence where they reside. 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