Tribal Certification Regarding Economic Conditions

OMB Approved No.

Expiration Date:

Department of the Treasury
Local Assistance and Tribal Consistency Fund

Certification Regarding Economic Conditions

I certify that I am an authorized representative of the Tribal government named below and that it is the assessment of the Tribal government that the economic conditions of the Tribal government are such that the Tribal government has a need for an award from the Department of the Treasury (Treasury) under the Local Assistance and Tribal Consistency Fund in the amount of $[   ] to provide services to members of the Tribe and others in its service community. Such services may include, but are not limited to, clean water, housing, child care, workforce development, the management of land and wildlife, and other examples of permissible uses of the award as outlined in Treasury’s guidance.  

Tribal Government:

Name of Authorized Representative:

Signature of Authorized Representative:

Date:

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