Tribal Affidavit

Guidance to Tribes for Completing Supplemental Request for Information

The information submitted on this form will be used to determine the second distribution of the Coronavirus Relief Fund to Tribal governments using the Coronavirus Relief Fund Tribal Allocation Methodology posted on Treasury’s website on May 5, 2020.

Employment Information

Enter the number of employees shown on line 1 of IRS Form 941 for each quarter of calendar year 2019. Include information separately for employees that are employed by the Tribal government directly and employees that are employed by any entity of which the Tribal government owns at least 51% of the ownership interests. Do not include any independent contractors or employees of independent contractors. If an entity was not in existence or otherwise had no employees for any calendar quarter in 2019, enter N/A for that quarter for the number of employees.

If there is more than one employing entity or more than one Employer Identification Number (EIN) for either line in the form, provide a separate schedule with details for each employing entity.

For each employer, submit a pdf file or other electronic copy of the supporting Form(s) 941 or equivalent third-party payroll service provider report(s) in electronic form. Employer identification information (name and EIN) and the information on line 1 of Form 941 is required; other information may be redacted.

If an employer files IRS Form 944 rather than Form 941, check the box indicating that the employer does not file IRS Form 941. Employers who file Form 944 are exempt from reporting the quarterly number of employees on this form.

Expenditure Information

Enter total governmental expenditures for the 12 months of the 2019 fiscal year in the line labeled “Total governmental expenditures”. Governmental expenditures include, but are not exclusive of, general government, public safety, health services, wellness services, substance abuse, general welfare and assistance, community services, cultural programs, education, recreation, housing, economic development, planning and development, sanitation, judicial, and similar activities, provided that capital outlays and debt service costs shall not be included within governmental expenditures.

In the line labeled “Total amount of federal financial assistance,” include amounts representing federal financial assistance included in the “Total governmental expenditures” line.

Submit a worksheet that shows how the dollar amounts are derived. Include links or relevant pages from financial documents to support the figures. Information provided on this form should be consistent with information presented by the relevant entity in any financial statement filed pursuant to the Single Audit Act or program-specific audit, as applicable.

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