Off grid assistance CF 1 App 2023

Off-grid Assistance Program 2023

The COVID-19 pandemic has disrupted supply chains, drastically increased the price of food, and lead to greater insecurity for Tribal members. Recognizing that there are members who do not qualify for utility assistance, the council has authorized onetime assistance to members who are unable to get assistance from the existing utilities assistance program (22T-002 This program is limited in duration; members will be served on a first-come, first-served basis and the program will remain open as long as funds remain available. Funding for this program comes from the BIA ARPA. Program requirements may be altered by guidance or notification from the U.S. Department of Interior. The Council allocated $10,000 of BIA ARPA funds to this program; the program will remain open until all available funds are expended. A Household may receive a grant of $2000 for the calendar year 2023. For applications in 2023, staff will contact the fuel supplier to credit the account of the applicant. The funds must be used for heating fuel, propane, or diesel.

Members may submit their receipts for 2023 in addition the application to info@gcorgetowntc.com. Alternatively, members can send receipts and applications to:

Native Village of Georgetown 5313 Arctic Blvd. Suite104
Full Member Name
Mailing address
Phone number
Email address
example@example.com
Enrollment number
Name of Supplier
Suppliers Address
Account #(if any)
The Native Village of Georgetown member will get a fuel credit at the supplier identified above for year 2023 only, to a maximum of $2000.
I certify have been impacted by the COVID-19 public health emergency. Initial
I certify household may be awarded up to $2000 per household for utility assistance.Initial
The number of NGV members in the household.
The number of NGV members in the household. I authorize the NVG to make a utility payment on my behalf. Initial
Check all that apply. My household has been impacted by:
Type a question

reduction in household income.Loss of Employment/Temporary Layoff/or Furlough.Been unemployed for at least 90 days before the date of this application.Reduction in hours/pay.Unable to work or experiencing financial due to no childcare/school.Underlying medical conditions require staying home to prevent exposure.Loss of self-employment/business income.Over the age of 50 and enduring increased costs because of the COVID- 19 pandemic.Enduring increased costs because of the COVID-19 pandemic.Incurred significant costs (hospital bills, medication costs, etc.)
*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@gcorgetowntc.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. lagree to verify the information provided in this application and to provide additional information to NVG if requested.
Print Name
Signature

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