(App#1) The Klamath Tribes COVID-19 (Coronavirus) Emergency Assistance March 1, 2020 to December 31, 2020 Program Application

- Step 1 of 8

(ONLY fill out this application if you did NOT get the 1st Covid Emergency Assistance Funding)

The Klamath Tribes

COVID-19(Coronavirus) Emergency Assistance

March 1, 2020 to December 31, 2020 Program Application Program Application

PROGRAM ELIGIBILITY 1) At least one member of the household must be an enrolled Klamath Tribal member 2) May reside in or outside of Klamath County, Oregon 3) Gross income for all Adults for last 30 days cannot exceed 60% OR State Median Income 4) Must demonstrate need for assistance as it relates to the COVID-19 Pandemic START DATES ELIGIBLE HOUSEHOLDS March 1st All households may apply for assistance.

REQUIRED DOCUMENTATION

Complete Application. All sections are complete and application must be signed.
Proof of enrollment in The Klamath Tribes. For at least one member of household (Information provided will be verified with the Member Benefits Department).
Income for all Adults for last 30 days. Proof of income or no income required for all Adults.

Please click all

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

RESIDENCY INFORMATION

Physical Address:

Address Line 1

City

State

Zip Code

Mailing Address *

Address Line 1

City

State

Zip Code

Phone *

1. Have you received similar assistance through other Tribal or State Programs? *

If yes, amount of assistance:($$)

2. Have you applied for assistance through other programs? *

3. Are you aware of available community resources? *

4. Do you receive Food Stamps, Commodities or TANF? *

SNAP/TANF benefit per Month($$):

ASSISTANCE SELECTION

Please mark the assistance you are seeking. Where appropriate, check will be made payable and mailed directly to the vendor.

SELECTION

Food
Personal Hygiene Products
Cleaning Products/Supplies
Medication

Medication – Vendor:

Remote Learning Capabilities for school aged children and college students

Utility/Heat

Vendor:

Acct. #

Allowable utilities: water, electricity, natural gas, propane, firewood, pellets, etc. *Double check your account number. Staff are not responsible if account number provided is incorrect and the utility company applies payment to the wrong account.

Rent/House Payment – Payable to:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Acct. # or other identifying info:

How has the COVID-19 (Coronavirus) affected your household’s ability to provide food, housing, or other needs identified above?

What is considered income?

Adoption Assistance
Alimony
Annuities
Cash gifts – regular
Child Support
Contract for Deed
Disability Insurance
Dividends
Earned Income (wages, salaries, bonuses)
Foster Care Payments
Informal Income
Inheritance
Interest
Lump Sum – non-recurring (only counted in the year the funds are received)
Lump Sum – recurring
Military Pay
Pensions
Rental Income
Retirement
Royalties
Self-Employment Income
Social Security Benefits (SS, SSD)
Supplemental Social Security Benefits (SSI)
Stimulus Check
Strike Benefits
Temporary Assistance for Needy Families (TANF)
Tribal TANF
Tribal General Assistance
Tribal Per Capita payments from gaming revenue, land leases, or other payments subject to federal tax
Trust Fund
Unemployment Insurance
Veterans Benefits
Workers Compensation

Proof of GROSS MONTHLY INCOME (before taxes, within last 30 days’ time period) is required for all Adults (18 years of age or older, not enrolled in High School or GED Program). If you have “no income” submit a Wage Printout. Wage Printouts are available from the Employment Office, at 801 Oak Ave., Klamath Falls, OR - (541) 883-5630.

Proof of income includes: check stubs, award or benefit letters. Bank statements are not valid proof of income, due to the following reasons: (1) Bank statements show net earnings, they do not show gross earnings, and (2) an individual’s source of income may be split in more than one bank account, and therefore a bank statement may not provide accurate total earnings.

Income 1 - Adult #1

Adult #1 *

First

Last

1. Income Source *

1. Amount *

1. Frequency *

1. Have Proof? *

2. Income Source

2. Amount

2. Frequency

2. Have Proof?

3. Income Source

3. Amount

3. Frequency

3. Have Proof?

Income- Adult #2

Adult #2

First

Last

1. Income Source

1. Amount

1. Frequency

1. Have Proof?

2. Income Source

2. Amount

2. Frequency

2. Have Proof?

3. Income Source

3. Amount

3. Frequency

3. Have Proof?

I hereby authorize the staff of the Klamath Tribes Administration to exchange information with the following agencies/programs:

Klamath Tribes Administration Departments / Programs
Klamath Tribal Health & Family Services Department / Programs
Klamath Tribes Enterprises
Klamath Tribes Gaming Regulatory Commission
Klamath Tribal Courts / Child Support Enforcement Program

Social Security Administration
Oregon Employment Department
Oregon Department of Health & Human Services
Domestic Violence Programs
Klamath Lake Community Action Services (KLCAS)
Other State, Federal and other Tribal Offices not listed herein

I hereby authorize the Klamath Tribes Administration staff or its agents, access to any records in order to verify information given. I also consent to any legally authorized investigation for confirmation of information from any State, Federal or Tribal offices or other agents so that I am eligible for assistance available through the COVID-19 Emergency Assistance. I understand I am not entitled to benefit from the COVID-19 Program.

If I receive assistance as a result of withholding information or by knowingly providing false or fraudulent information, I must repay the assistance and may be found guilty of fraud and fined up to $10,000 or put in prison or both. I understand I may be entitled to a fair hearing if requested within fifteen (15) day of completed date of application or date of denial. I understand that no person may be denied assistance on the basis of race, color, sex, age, religion, national origin or political belief. 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 understand that if I am approved, I may be notified at a later date.

Name *

First

Last

Signature