Quarantine Assistance Form

Members of the Native Village of Georgetown can request assistance for food or lodging for quarantining. The program is available July 20, 2020, to December 30, 2024. Assistance is a one-time payment per member. Exceptions may be made for elders 65 years and older.

Member Name

Address, City/State/Zip Code

Request is for

Lodging for the purposes of quarantining as requested by a public health officialFood Delivery or Food Purchase up to $750 per household member that test positive for COVID on a reimbursement basis (submit receipts).

List any additional Georgetown members in your household that have tested positive for COVID-19 and need to quarantine.

My quarantine begins on:

I certify that my food security was impacted by the need to quarantine. (Initial)

Submit proof of need to quarantine for yourself as well as those listed above.

By signing below, I the member listed above, certify that the above information is true and correct to the extent of my knowledge. I understand that knowingly submitting false or incomplete information may be considered a crime under tribal, state, and federal law. I further agree that the funds distributed by Georgetown shall be used for the purposes intended under the CARES Act and only for "necessary expenditures incurred due to the public health emergency for the Coronavirus Disease.' I have not received funds for a similar item or program. I acknowledge that the Georgetown Tribal Government must comply with the conditions outlined in the CARES Act and by the U.S. Department of Treasury. All expenditures made on my behalf and those I am applying for may be subject to federal audit by the u.s Government

(Signature)

(Date)