COVID ER FORM — Village of Solomon

EMERGENCY COVID APPLICATION

The Village of Solomon has declared a public health emergency for the VOS tribally enrolled community due to the COVID-19 pandemic. In order to meet the immediate and critical needs of tribal members, VOS has established a COVID-19 EMERGENCY Relief Assistance Grant Program that is available through an application process. Tribal members that TEST POSITIVE for COVID19, are eligible to apply for emergency financial assistance during isolation and quarantine BASED ON THE STATEMENT OF NEED. Eligible expenses are as follows; rent/mortgage, delivered groceries, any health expenses related to COVID19, phone services, utilities, etc. due to loss of income and/or due to a COVID-19 positive test result. Please explain below your circumstances and the Village of Solomon will process your application as soon as possible.

Name

First Name

Last Name

Tribal Enrollment

Physical Address:

Mailing Address:

Phone Number:

Please Check the item(s) that you and your household need assistance with

Heating Fuel Company:

Utilities/Electric/Power Company

Food/Groceries

Internet/Cable

Phone Carrier

Rent/Mortgage Assistance (List landlord or mortgage lender contact info)

Other (please explain):

You must email any and all supporting documentation for which you are requesting financial assistance. This will expedite the review process. Examples of documentation; receipts, invoices, bills paid, paystubs, termination letters, fees for service - all must show covid related need. Please also attach a copy of your COVID-19 positive test results, dated with patients name.

Household Information

Name, DOB, Relation to Head, Age, Sex, Enrollment #

Please explain your circumstances below:

I am experiencing genuine financial need as a result of the COVID-19 pandemic as follows (check all that apply):

Please select the BEST description of your circumstances

By Signing Blow, I hereby certify that I have ben conomically affeected by the COVID-19 pandemic and have incurred related expenses including, but not limited to the following: loss of income, food, housing, distance learning, healthcare, telehealth, telework, childcare, or other public health and safety needs and services. I am applying for COVID-19 relief assistance to meet the basic needs for myself and my household.

Signature

Date