COVID-19 Support Application – Blackfeet Nation

First Name *

Last Name *

Email

Phone

Date of Birth (MM/DD/YYYY) *

Tribal Enrollment No. *

Address *

Address

City

State/Province

Zip/Postal

Do you want this to be your address on your enrollment file? *

Yes

No

How will you receive your check? *

Mail check to address on application

Pick up check from disbursement site

Please list all Blackfeet Tribal household members 17 years of age or younger not previously applied for. MUST INCLUDE: First and Last Name, Relationship, DOB and Enrollment number

Any children subject to court order for custody or guardianship?

Yes

No

If you answered yes above, please attach court orders for custody or guardianship if not on file with the Tribe. If you are not able to upload, you can email your court order to bmpcovid19@gmail.com or fax it to (406) 338-5339.

Maximum file size: 52.43MB

Financial Need

Certification

Please certify your answers: *

I/we certify that the information contained herein is true and correct to the best of my/our knowledge.

I/we certify that these CARES Act funds I/we received from the Tribes shall be used for the economic impacts of COVID-19 for me (and/or my family) that I/we have and are experiencing.

I also certify that I have physical custody and/or legal guardianship for the above-named children or dependents.

Signature *

Clear

Date *

COVID-19 SUPPLEMENT PAYMENT APPLICATION

IMPORTANT DATES & CONTACT INFORMATION

APPLICATION FORM

Financial Need

Certification