NV Georgetown Broadband supplemental assistance form

2024 Broadband Supplemental Assistance Form

Full Member Name

Phone number

Mailing address

Email address

example@example.com

Enrollment number

Certifications

I have been impacted by the COVID-19 public health emergency. Initial

I understand each household will be awarded up to $100 per month to reimburse a portion of the broadband internet bill. Initial

This program will run from June to November 2024 and is one per household.

The funding only covers broadband internet (cable, satellite, fiber optic) and does not cover cellular data.

Please send in copies of your broadband internet bill or if it it is part of a bundled service, include the portion of the bill that shows the itemized billing costs for the broadband internet service.

**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

Date