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.

APPLICANT INFORMATION

#1

Applicant Name *

First

Last

Date of Birth *//

Age of Applicant *

Applicant Roll Number *

#2

Applicant Spouse/Dependent

First

Last

Relationship to Applicant

Date of Birth//

Age of Relation

Applicant Roll Number

#3

Dependent Name

First

Last

Relationship to Applicant

Date of Birth//

Age of Relation

Applicant Roll Number

#4

Dependent Name

First

Last

Relationship to Applicant

Date of Birth//

Age of Dependent

Applicant Roll Number

#5

Dependent Name

First

Last

Relationship to Applicant

Date of Birth //

Age of Dependent

Applicant Roll Number'

Additional Dependents (if none, skip to next)

#6

Dependent Name

First

Last

Relationship to Applicant

Date of Birth//

Age of Dependent

Applicant Roll Number

#7

Dependent Name

First

Last

Relationship to Applicant

Date of Birth//

Age of Dependent

Applicant Roll Number

#8

Dependent Name

First

Last

Relationship to Applicant

Date of Birth//

Age of Dependent

Applicant Roll Number

#9

Dependent Name

First

Last

Relationship to Applicant

Date of Birth//

Age of Dependent

Applicant Roll Number

Contact Information

Mailing Address *

Address Line 1

City

State

Zip Code

Phone *

Email

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