ARPA STIMULUS APPLICATION 2022

Leech Lake Band of Ojibwe American Rescue Plan Economic Relief Payment 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 18 years of age and enrolled with Leech Lake Band of Ojibwe as of 7/11/22.

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 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 $1,700.00.
Name (full legal name as shown on Government issued ID)*

First NameMiddle NameLast NameSuffix (Jr. Sr. III)
Date of Birth*

MonthDayYear
Date
Social Security Number*
Leech Lake Band of Ojibwe Enrollment #*
Incorrect Enrollment number will result in your application being denied.
Phone Number*

Area CodePhone Number
Email
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Physical Address (if different from mailing)

Street Address

Street Address Line 2

CityState

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

YesNo
If Yes, Check all that apply:*

Furloughed or Terminated from EmploymentUnemployed at start of pandemicIncreased Health Care ExpensesIncreased Child Care ExpensesIncreased Grocery and/or Food Delivery ExpensesExpenses related to Home-SchoolingExpenses related to working remotelyPurchase of Personal Protective Equipment and Cleaning SuppliesMember Owned Business closed or run at diminished capacityQuarantine CostsOther
I would like my payment issued via (please select one option):*

Debit CardCheck
Where will you be collecting your payment:*

U. S. Mail
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 and Accounting database.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Leech Lake Band of Ojibwe American Rescue Plan Economic Relief Payment to Tribal Members Verification of Need Form

Economic Impact Directly Related to COVID-19 Pandemic