2nd Financial Relief Distribution

The Native Village of Kotzebue has announced asecond financial relief distributionto its Tribal members who were effected by COVID-19 andare of record on or before November 9, 2020

To receive these funds, apply online at www.qiracovid.org prior to December 10, 2020; please call our COVID-19 response hotline at (907) 442-5317 or email the processing team to Cares@QIRA.org for more information. You will be required to supply a W-9 if you have not already supplied one during the first distribution.

There are paper applications available for pick-up outside of the office in the Applications and drop box at the top of the stairs; due to the rise of COVID-19 cases we are currently closed to the public and you MUST have an appointment to enter into our building.

Please complete this application and submit to the Tribal Office no later than DECEMBER 10, 2020.
Attach guardianship paperwork if not parent.
Incomplete applications will not be considered.

Step 1 of 4

Section 1 - Applicant Information
First & Last Name*
First Last
Maiden Name
Maiden
Social Security Number (Last 4 Digits)*
Residential Address*
Street Address City State ZIP Code
Mailing Address
Street Address City State ZIP Code
Telephone Number*
Tribal members who would like text messaging updates please provide your cell phone number:
Date of Birth*
Email Address*
If Applicant is NOT a tribal member, explain:

Section 4 - APPLICANT CERTIFICATION
Did you receive 1st Financial Relief Distribution?*
- Yes
- No
Upload W-9*
If needed you can find W-9 form here: https://www.irs.gov/pub/irs-pdf/fw9.pdf
Applicant Certification*
By checking this box I acknowledge the following:*
I, the undersigned applicant, hereby certify under penalty of perjury, that all information in this Application is true and correct to the best of my knowledge, information and belief.

I understand that all funds I receive as a result of this application must be used for COVID-19 related needs as stated above. I certify that the COVID-19 expenses I have identified will not be covered by CARES Act funds from any other source, including unemployment payments. I certify that I will not apply for funding from any source for the costs, expenses and losses that are covered by funds received from this application. I understand that I will be required to reimburse the Tribe or U.S. government for any misuse of funds or payments made to me based on inaccurate statements or material omissions. The Tribe reserves all rights under law to recover funds paid by mistake of law or fact. I agree to assist the Tribe in obtaining any further verification of submitted information upon reasonable request. I understand if my application is denied I may request a copy of the Dispute Resolution procedure from the Tribe.
Signature of Applicant (Type In Full Name)*
First
Today's Date*
Date Format: MM slash DD slash YYYY
Selected - Person completing this application is a guardian or custodian of a child under 18, or is the guardian, conservator, or power of attorney of an adult tribal member
- Check this box if the person completing this Application is a guardian or custodian of a child under 18, or is the guardian, conservator, or power of attorney of an adult tribal member. Supporting verification will be required.
Email
This field is for validation purposes and should be left unchanged.

Online - Emergency COVID Financial Relief Application