NVG PHS form UPDATE CF5 24

Full Member Name*
Address*

Mailing address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Phone number*
Email address
example@example.com
Enrollment number
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 $1000 per month for up to six 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. The funding period runs until November 30, 2024, with the final payment to be made before December 15, 2024.

Note: firewood can be purchased in advance instead of monthly to a maximum of $6000
Certifications
I certify have been impacted by the COVID-19 public health emergency
Initial
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:
Type a question

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.).
**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 below. 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.

Native Village of Georgetown

5313 Arctic Blvd, Ste 104

Anchorage, AK 99518

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.

Indicate where the grant award should be distributed. To not exceed $1000. Submit copies of bills to info@georgetowntc.com or by mail to the address below.

	Utility Company Name	$ Amount	Utility Account #
Electric
Water/Sewer
Trash
Natural Gas
Firewood

Print Name*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: