COVID-19 Financial Assistance Application

Leech Lake Band of Ojibwe Emergency Relief Assistance to Tribal Members Verification of Need Form

This is a need-based financial assistance program for adult, enrolled Leech Lake Band of Ojibwe tribal members who have been financially impacted by COVID-19.
Program Eligibility Requirements:

1. Must be an enrolled LLBO Tribal member.

2. Must be enrolled with Leech Lake Band of Ojibwe as of 10/23/20.

3. Must demonstrate a need for assistance by checking at least one box on the Economic Impact Directly Related to COVID-19 Pandemic below.

*4. Individual must sign and return this Form on or before 12/14/20 to Leech Lake Band of Ojibwe, Emergency Relief Assistance, 190 Sailstar Dr NW, Cass Lake, MN 56633

Eligible Tribal members 18 and over may receive a one-time payment of $250.00.
Name *

First Name Middle Name Last Name Suffix
Date of Birth *

Month Day Year
Date
Last 4 Digits of Social Security Number *
Leech Lake Band of Ojibwe Enrollment # *
Incorrect Enrollment number will result in your application being denied.
Phone Number *

Area Code Phone Number
Email *
example@example.com
Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code
Physical Address (if different from mailing)

Street Address

Street Address Line 2

City State

Zip Code
Economic Impact Directly Related to COVID-19 Pandemic
Are you experiencing financial hardship as a result of the COVID-19 pandemic? *

Yes No
If Yes, Check all that apply: *

Furloughed or Terminated from Employment Unemployed at start of pandemic Increased Health Care Expenses Increased Child Care Expenses Increased Grocery and/or Food Delivery Expenses Expenses related to Home-Schooling Expenses related to working remotely Purchase of Personal Protective Equipment and Cleaning Supplies Member Owned Business closed or run at diminished capacity Quarantine Costs
Disclaimer: In submitting this application, I declare and certify that the information and documentation is true and correct regarding the impact of the COVID-19 public health emergency. I further agree to assist the LLBO in seeking any further necessary verification of the submitted information upon reasonable request.

Contact information submitted on this form will be updated in the Tribal Enrollment database.
Signature *

Clear
PRINT NAME *
Date *

Month Day Year
Date
Should be Empty:

Leech Lake Band of Ojibwe Emergency Relief Assistance to Tribal Members Verification of Need Form

Economic Impact Directly Related to COVID-19 Pandemic