ARP Negative Economic Impact Assistance

Crow Creek Sioux Tribe is providing assistance to current on and off reservation members who are enrolled as of June 30, 2021. This assistance is for the Negative Economic Impacts that have been caused by the COVID-19 Pandemic. All enrolled members are eligible to apply for this ARP funding.

Applicant Name (Head of Household) *

First

Middle

Last

Enrollment Number *

Date of Birth *

Email *

Phone *

Mailing Address *

Address Line 1

City

State

Zip Code

Physical Address *

Address Line 1

City

State

Zip Code

Areas of negative economic impact you and your family have suffered *

Lost of Income (job lost, furloughed, laid off, reduced hours, business closed, etc.)
Increased cost of living (increase in monthly food bill, utilities, accessing essential services)
Increased cost of health care (50+, disabled, underlying health conditions, self and household member)
Added costs for household safety and protection from COVID-19 (clothing, sanitation, etc)
Added costs of dependent care (distant learning, child care, health and wellness)
Loss of income due to head of household death from COVID-19
Funeral expenses due to death of family member(s) from COVID-19
Added costs of care of family member(s) due to CVID-19 symptoms
Other

Areas of negative economic impact (OTHER)

I verify that I am the Legal Parent/Guardian of the following minor child(ren) enrolled in CCST as of June 30, 2021.

Child 1

First

Middle

Last

DOB 1

Enrollment#

Child 2

First

Middle

Last

DOB 2

Enrollment#

Child 3

First

Middle

Last

DOB 3

Enrollment#

Child 4

First

Middle

Last

DOB 4

Enrollment#

Child 5

First

Middle

Last

DOB 5

Enrollment#

Child 6

First

Middle

Last

DOB 6

Enrollment#

Child 7

First

Middle

Last

DOB 7

Enrollment#

Child 8

First

Middle

Last

DOB 8

Enrollment#

Child 9

First

Middle

Last

DOB 9

Enrollment#

Child 10

First

Middle

Last

DOB 10

Enrollment#

Child 11

First

Middle

Last

DOB 11

Enrollment#

Child 12

First

Middle

Last

DOB 12

Enrollment#

Affirmation *

I agree with the following statement:

I certify that this form is being submitted by the applicant and that the above information is correct and true to the best of my knowledge. I understand that Legal Guardianship of a minor child(ren) may require documentation and verification through a current court order. I understand that false statements made herein are subject to re-paying the ARP assistance as well as Tribal and Federal prosecution.