Tribal Employment Information Form

OMB Approved No.: 1505-0271

Expiration Date: 11/30/2021

Coronavirus State Fiscal Recovery Fund

Tribal Government Employment Information Form

May X, 2021

Each Tribal government must confirm or amend its 2019 employment numbers as provided below by June 21, 2021, in order to be eligible to receive a payment based on its share of the employment allocation as described in the Tribal governments allocation methodology. A Tribal government that does not submit this information will not receive this payment.

Eligible Tribal governments include the recognized governing body of any Indian or Alaska Native tribe, band, nation, pueblo, village, community, component band, or component reservation, individually identified (including parenthetically) in the list published by the Bureau of Indian Affairs in the Federal Register at 86 FR 7554 (Jan. 29, 2021), available at https://www.federalregister.gov/documents/2021/01/29/2021-01606/indian-entities-recognized-by-and-eligible-to-receive-services-from-the-united-states-bureau-of.

Did the Tribe submit 2019 employment numbers to the U.S. Department of the Treasury for the Coronavirus Relief Fund? [ ] Yes [ ] No

If “No,” provide the following information:

	Calendar Year 2019
Number of Employees*	Q1	Q2	Q3	Q4
Employed by Tribe
Employed by Tribal Entities

* Employees: Total number of persons employed by the Tribal government and any tribally owned entity (to include entities in which the Tribal government maintains at least 51% ownership) on January 1, 2020.

Did the Tribe file an IRS Form 941? [ ] Yes [ ] No

If “Yes” upload all applicable Forms 941 for each employing entity.

If “No” please upload other supporting information for employment counts.

If “Yes,” do you have reasons to amend 2019 employment numbers as submitted for the Coronavirus Relief Fund (shown below)?

[ ] Yes [ ] No

If “No,” no further information is needed at this time.

If “Yes,” provide amended 2019 employment numbers below:

	Calendar Year 2019
Number of Employees*	Q1	Q2	Q3	Q4
Employed by Tribe
Employed by Tribal Entities

* Employees: Total number of persons employed by the Tribal government and any tribally-owned entity (to include entities in which the Tribal government maintains at least 51% ownership) on January 1, 2020.

Does the Tribe file an IRS Form 941? [ ] Yes [ ] No

If “Yes,” upload all applicable Form 941s for each employing entity.

If “No,” please upload other supporting information for employment counts.

I hereby certify that I am authorized by the Tribal government to submit the information included with this form and that it is true and correct to the best of my knowledge. I further understand that a materially false, fictitious, fraudulent statement or representation (or concealment or omission of a material fact) in this form may be the subject of criminal prosecution under the False Statements Accountability Act of 1996, as amended, 18 U.S.C. § 1001, and also may subject me and the Tribal Government to civil penalties, damages, and administrative remedies for false claims or otherwise (including under 31 U.S.C. § 3729 et seq.).

_________________________________________________________
Signature of Authorized Representative Name: Date: Title: Name of Recipient:

PAPERWORK REDUCTION ACT NOTICE

The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of information is 45 minutes per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number assigned by OMB.