CARES Act Emergency Relief Funds Verification Form and Instructions

The Lac Courte Oreilles Tribal Governing Board has approved the use of a VERIFICATION FORM to distribute emergency relief funds from the CARES Act for enrolled Tribal Members. The following VERIFICATION FORM must be completed by eligible enrolled tribal members and returned to the Tribal Government Office.


There are three ways the completed forms can be returned to the Tribal Government Office:


1) Drop off at the mailroom in the Tribal Government Office; or 2) Fax to 715-634-4797; or

3) Mail to Tribal CARES Act Emergency Relief Funds Verification, LCO Tribal Government, 13394 W Trepania Road, Hayward WI 54843.


Any person who is an officially enrolled Tribal Member of the Lac Courte Oreilles Band of Lake Superior Chippewa Indians as of June 1, 2020 will be eligible for the CARES Act COVID-19 Emergency Relief Funds.


Each enrolled tribal member must fill out a separate verification form. Parents, guardians, or legal custodians must fill out a form for each minor child or person under guardianship or in placement.


Please check each applicable box to document how your household has been impacted by the COVID-19 pandemic. Also sign and print your name at the end of the form.


Details are still being worked out and a date has not yet been set as to when the payments will be distributed. Please continue to visit the Tribe’s website,, or follow the Tribe’s Facebook page, Lac Courte Oreilles Band of Lake Superior Chippewa Indians.

Below you you will find two versions of the form, a PDF you can open, download and print, or an image you can click, save to your computer and print.

CARES Act verification page 1.png
CARES Act verification page 2.png