NVG PHS form CF5 2022

2022 Utility Assistance Program

On March 26, 2022, the Native Village of Georgetown (NVG) established a Utility Assistance Program using funds from the American Rescue Plan Act (ARPA) to assist NVG members adversely impacted by the public health emergency. In developing program guidelines, NVG strived to balance the urgency of the need of our members with a process that will ensure transparency, efficiency, and the responsible management of ARPA funds. In developing this program, NVG conducted surveys and contacted local agencies to better understand the membership impacts related to the COVID-19 public health emergency and target available funds to the areas of greatest need. Several common themes emerged from local research and were incorporated into the program. The NVG also reviewed and learned from similar programs around Alaska. This program was designed to provide timely financial relief to members in the NVG experiencing financial hardship directly caused by the COVID-19 public health emergency.

Goals and Objectives

The COVID-19 pandemic has underscored the need for safe and sanitary living conditions to improve public health. The NVG, recognizing that there is a need to improve the living conditions for our members, authorizes the payment for the following utilities: electricity, solid waste, water, and sewer.

This program is funded by ARPA and may be altered at any time based upon guidance or notification from the US Department of Treasury.

The payments will be made directly to the utility or city government that manages the above services for ongoing services or may be provided to the member as reimbursement for invoices already paid. Members may be awarded up to a household limit of $500 per month for up to four months per year. In compliance with federal guidelines, the member will need to certify that the member has not used a similar program in conjunction with this program.

Allowable Use of Funds

The funds must be used solely for necessary expenditures due to the COVID- 19 public health emergency. Members may be awarded a household limit of $500 per month for up to four months per year. Applicants must self-certify that they have been financially impacted by the COVID-19 public health emergency and may be required to provide a brief description of the negative impacts

Applicants must self-certify that no members in the applicant's household have used a similar program or obtained duplicate relief.

The Tribal Liaison and Tribal Administrator will determine whether the application is complete and the individual meets program requirements. Submission of incomplete or inaccurate applications may result in ineligibility for funding. The incomplete application will be sent back to the member until the application is complete.

The NVG reserves the right to amend the criteria or procedures of this program as may be required to conform with state and federal guidelines.
Full Member Name
Mailing address (include city, State, zip)
Phone number
Email address
example@example.com
Enrollment number
I certify have been impacted by the COVID-19 public health emergency.
Initial
The number of members in the household.
I authorize the NVG to make a utility payment on my behalf.
Initial
Check all boxes that apply to your household. My household has been impacted by:

reduction in household income.Underlying medical conditions require staying home to prevent exposure.Loss of Employment/Temporary Layoff/or Furlough.Loss of self employment/business income.Been unemployed for at least 90 days before the date of this application.Over the age of 50 and enduring increased costs because of the COVID 19 pandemic.Reduction in hours/pay.Enduring increased costs because of the COVID 19 pandemic.Unable to work or experiencing financial hardship due to no childcare/school.Incurred significant costs (hospital bills, medication costs, etc.).
Indicate where the grant award should be distributed. To not exceed $500.
Assistance to Electric (utility company name)
Amount
Account number
Assistance to Solid Waste (utility company name)
Amount
Account number
Assistance to Sewer (utility company name)
Amount
Account number
Assistance to Water (utility company name)
Amount
Account number
**Please note: the Individual Assistance grant program is only open to NVG members** NVG recognizes the need to support tribal members as a result of the COVID-19 public health pandemic. The individual grant is aimed to help NVG members economically impacted by the COVID-19 public health emergency for utility assistance. By applying, there is no guarantee or obligation that funds will be awarded. The application will be kept confidential and remain within the NVG. Please answer each question to the best of your knowledge. Incomplete applications will be rejected.

Applications may be submitted by email to info@georgetowntc.com hand-delivered or mailed to the

address above. Incomplete applications will be rejected. Applicants will be notified of the status of their application via email to the contact person listed on the application. It is the applicant's sole responsibility to determine or seek independent advice as to the tax implications of receiving the funds.

I certify that the information provided in this application is true and accurate. I agree to verify the information provided in this application and to provide additional information to NVG if requested.
Print Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: