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* 1. I certify that I have experienced financial need and have or will incur additional necessary expenditures between March 1, 2020 and December 30, 2020 resulting directly from the COVID-19 public health emergency as follows (check all that apply):

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* 2. Contact information and enrollment number

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* 3. Because the Emergency Disaster Relief Payment is funded with federal funds from the CARES Act Coronavirus Relief Fund which is subject to audit, the Nation recommends that members keep receipts to the extent possible.

I certify that the foregoing expenses have not been reimbursed by other sources and agree that I have or will use the Emergency Disaster Relief Payment to cover these necessary COVID-19 expenses.

I certify and agree that I will return to the Nation any portion of the Emergency Disaster Relief Payment that exceeds my actual unreimbursed expenses resulting from the COVID-19 public health emergency.

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* 4. Name of Member or Legal Guardian/POA 

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