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The Klamath Tribes COVID-19 (Coronavirus) General Welfare Emergency Assistance Program Application October 19, 2020 to December 31, 2020 Program Application
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Step
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The Klamath Tribes
COVID-19(Coronavirus) General Welfare Emergency Assistance Program Application
October 19, 2020 to December 31, 2020
Program Application
Purpose
The COVID-19 General Welfare Emergency Assistance Program is designed to provide financial assistance to Klamath Tribal members and their dependents worldwide for necessary expenditures to respond to the COVID-19 public health emergency. This program allows our eligible Klamath Tribal members to prevent, prepare, and respond to the COVID-19 public health emergency.
Program Eligibility
Must be an enrolled Klamath Tribal member or have an enrolled Klamath Tribal member dependent;
May reside in or outside of Klamath County, Oregon;
Applicant and/or minor child or child in care has been affected by one of the identified COVID-19 Criteria;
Must submit a complete application.
COVID-19 Criteria – Please mark all that apply.
*
Loss of job, reduced working hours, loss of income due to COVID-19;
COVID-19 related medical expenses not otherwise covered;
Costs and Expenses necessary to protect and preserve individual health;
Costs and Expenses needed to protect against unexpected, long-term isolation including but not limited to the emotional and psychological toll resulting from the loss of traditional family association and Tribal customs;
Emergency medical response expenses, including emergency medical transportation;
Expenses and costs to maintain quarantine or in quarantining individuals;
Expenses to facilitate distance learning, including technological improvements in connection with school closures;
Expenses related to sanitation and improvement of physical distancing measures;
Expenses associated with the provisions of economic support in connection with the COVID-19 public health emergency;
Expenses related to overdue rent or mortgage payments to avoid eviction or foreclosure;
Unforeseen financial costs for funerals;
Expenses and costs that directly affected your household’s ability to provide food, housing, or other subsistence needs;
Costs for elder assistance with technology, internet and equipment; and
Other individual emergency needs to preserve or protect Klamath Tribal lives, traditions and customs.
Next
APPLICANT INFORMATION
#1
Applicant Name
*
First
Last
Date of Birth
*
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Age of Applicant
*
Applicant Roll Number
*
#2
Applicant Spouse/Dependent
First
Last
Relationship to Applicant
Date of Birth
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Age of Relation
Applicant Roll Number
#3
Dependent Name
First
Last
Relationship to Applicant
Date of Birth
MM
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Age of Relation
Applicant Roll Number
#4
Dependent Name
First
Last
Relationship to Applicant
Date of Birth
MM
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YYYY
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Age of Dependent
Applicant Roll Number
#5
Dependent Name
First
Last
Relationship to Applicant
Date of Birth
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1921
1920
Age of Dependent
Applicant Roll Number'
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Next
Additional Dependents (if none, skip to next)
#6
Dependent Name
First
Last
Relationship to Applicant
Date of Birth
MM
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DD
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YYYY
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2015
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1981
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1921
1920
Age of Dependent
Applicant Roll Number
#7
Dependent Name
First
Last
Relationship to Applicant
Date of Birth
MM
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1931
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1922
1921
1920
Age of Dependent
Applicant Roll Number
#8
Dependent Name
First
Last
Relationship to Applicant
Date of Birth
MM
1
2
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5
6
7
8
9
10
11
12
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DD
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YYYY
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2020
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2013
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1931
1930
1929
1928
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1925
1924
1923
1922
1921
1920
Age of Dependent
Applicant Roll Number
#9
Dependent Name
First
Last
Relationship to Applicant
Date of Birth
MM
1
2
3
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5
6
7
8
9
10
11
12
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DD
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YYYY
2021
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2015
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2013
2012
2011
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1981
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Age of Dependent
Applicant Roll Number
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Next
Contact Information
Mailing Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
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Benefit
Determination
Applicants who have contracted COVID-19 or who reside within a residence shared by someone who has contracted COVID-19
– will receive a payment of $2,500. The Applicant must provide documentation confirming the positive test for the virus.
Other eligible Applicants
– All other Tribal Members who are applicants or are listed on an application as a member of a household and are 18 years of age and over will receive a payment of $1,500. Separate applications are to be completed and submitted for processing.
Dependent minors who are Tribal Members within a Household
– Households will receive an additional $500 for dependent minor Tribal Member under the age of 18 living within the Household. If an Applicant is a non-tribal member who has dependent Tribal Members in his/her Household, the Applicant will receive $1,500 for the first dependent and $500 for each additional dependent minor Tribal Member.
Applicants that have contracted COVID-19
and remain unemployed for more than 30 days due to the coronavirus or employment policies that prohibit return to work and can provide supporting document from employer will receive an additional $1,500 for covering monthly living expenses.
Benefits for technology
-will be determined separately.
Applicants that have received initial $1,500 general welfare emergency assistance and later contract COVID-19
– are eligible to receive an additional $1,000 to make a total of $2,500 in general welfare assistance and be compliant with the above benefit identified above in no. 1 of this section.
Benefit Payment
Assistance will be provided in accordance with the approved COVID-19 General Welfare and Emergency Assistance Policy and program eligibility criteria. In addition, the program will be structured to follow the CARES Act Funding Guidelines, Title 26 Internal Revenue Code, Section 139 Disaster Relief Payments and Section 139E Indian General Welfare Benefits. Requested assistance is not to be duplicative of other CARES Act or unemployment compensation received. If funds are not needed and used as required per the CARES Act, the applicant is required to return any unused funds to the Tribe by December 30, 2020.
Release of Information/Disclaimer
I hereby authorize the Klamath Tribes Administration staff or its agents, access to pertinent program records in order to verify information given. This includes but is not limited to the request for information from any State, Federal, and Tribal programs or other agents to determine that I am eligible for assistance available through the COVID-19 general welfare emergency assistance. I understand that the program is general welfare assistance and not an entitlement. If I receive assistance by knowingly providing false or fraudulent information, I must repay the assistance to The Klamath Tribes by December 30, 2020. I agree to all terms of this disclaimer and am allowing the Klamath Tribes Administration access to my personal information to process my Application. By signing this application, I declare that at least one of the COVID-19 criteria listed in this application applies to myself and/or to any minor child or children in my care, control or custody.
Name
*
First
Last
Signature
Clear Signature
Submit