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Round Two Now Available
Round Two Now Available
Federal CARES Act Tribal Relief Funds for Goldbelt Shareholders
Please provide the information for the applicant below. Applicant must be a Goldbelt shareholder as of October 12, 2021. Each shareholder is required to complete an application. Applications submitted on behalf of a minor require additional certifications at the end of the application.
Goldbelt Shareholder ID
To locate your shareholder ID, login to MyGoldbelt.com and click on the certificate button or call Shareholder Services.
Address Line 1
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date of Birth
MM slash DD slash YYYY
If submitting the application on behalf of a minor, please sign and certify for the minor before submitting the application.
Would you like to update your contact information on file with Goldbelt?
If you check "yes," Goldbelt will update your information to reflect your answers from this application.
ASSESSMENT OF INDIVIDUAL NEED – FINANCIAL IMPACTS OF COVID-19
Please select ALL boxes that may apply to any financial loss, necessary expenses incurred, or emergency economic need you experienced or are experiencing due to the COVID-19 Pandemic, and, if applicable provide additional explanation in the box provided below. The purchases or losses must have occurred between March 2020 and December 2021, and these expenses were not accounted for in the initial Goldbelt CARE Act application program launched in August 2021 or other tribal relief program(s).
Financial loss resulting from interruption of employment, such as job loss (including resignation to provide care for family members), decreased work hours, furlough, unpaid leave
Financial loss resulting from business interruption, such as lost small business income, lost rental income, and similar costs
Expenses for COVID-19 testing and medical treatment
Expenses for acquisition of medical and protective supplies, including, but not limited to, sanitizing products and personal protective equipment
Expenses for increased or extraordinary utility costs
Additional expenses for cleaning and sanitization
Additional expenses for childcare and education
Increased costs of food or traditional food support including storage and gathering
Expenses to facilitate distance learning or improve telework capabilities, including technological improvements (such as computer hardware and software), and enhanced connectivity
Emergency financial assistance needed to cover the costs of utilities
Emergency financial assistance needed to avoid eviction, foreclosure or food insecurity
Emergency financial assistance for funeral expenses and other emergency economic needs
Other, please provide details below*
*Other Covid-Related Expenses (Optional)
If you selected "other" from the checklist above, please provide additional details below.
Financial Amount of Reimbursement Requested:
The CARES Team will match the amount certified above up to but not exceeding $800.00. Based on the options provided above, please consider all financial losses, necessary expenses incurred, and emergency economic assistance needed due to the COVID-19 pandemic (cannot duplicate expenses from previous expenses).
I certify that I am a United States citizen.
I certify that I am submitting this form to Goldbelt, Inc. to request relief from financial impacts caused by the COVID-19 pandemic.
I certify that all information provided is accurate to the best of my knowledge.
I certify that these one-time Federal CARES Act funds may impact other assistance programs as it may be counted as unearned income. Please note, SSA will not count these funds against an individual's benefits.
I certify to the best of my knowledge that the amount requested is accurate and reflective of the amount paid to cover costs caused directly by the COVID-19 pandemic.
I certify that specific purchases or losses were not accounted for in the initial Goldbelt Federal CARES Act application or other tribal relief program.
Minor Certification (optional)
I certify that I am the parent or legal guardian of the minor shareholder for this form.
I certify that this form reflects the MINOR'S increased costs and/or financial loss as a result of the COVID-19 pandemic and not the household as a whole.
Please type your name in the box below to serve as your e-signature.
This field is for validation purposes and should be left unchanged.