Tunica Biloxi Tribal Member Health & Housing Request Form
Under the Tribal General Welfare Exclusion Act of 2014 Tunica-Biloxi tribal members may qualify for Health and Housing Assistance. This Act allows tribal governments to provide financial assistance without tax withholding under certain approved tribal government programs for specific reasons. To qualify, the Act requires that all Tunica-Biloxi tribal members complete this form each year in order to qualify for Health & Housing Assistance. Please take a moment to complete this form in order to apply for the Tunica-Biloxi Health and Housing Assistance Program.
First Name *
Your answer
Last Name *
Your answer
Please provide your current contact information below .
Current address on file with the Tribal Government *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Email Address *
Your answer
Please complete the following questions.
Are you 18 years old or older? *
Please provide your Tribal Roll #: *
Your answer
What is your Date of Birth ? *
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What is the Date of Birth of EACH member of your household? Please list each family member's name and DOB:
Your answer
Do you or any members of your household have a disability? If so, please list the person’s name, age, disability diagnosis and assistance that may be required:
Your answer
Please review the below statements and confirm that you understand and agree with each.
Assistance Payments for Housing
I understand that under this program Assistance Payments relative to housing must be used only for principal residences and ancillary structures that are not used in any trade or business or for investment purposes. I understand that Assistance Payments are to be used only for the following purposes: to pay mortgage payments, down payments or rent payments (including but not limited to security deposits) for principal residences; to enhance habitability of housing; to provide basic housing repairs or rehabilitation; to pay utility bills and charges (including but not limited to water, electricity, gas and basic communications).
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Required
Assistance Payments for Health
I understand that Assistance Payments for health (medical care) must be used only for reimbursement of amounts paid for the following: for the diagnosis, cure, mitigation, treatment or prevention of disease or for the purpose of affecting any structure of function of the body; for transportation primarily for and essential to medical care; for long-term care services; and/or for insurance covering medical care or a long term care insurance contract.
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Required
Confirmation of Identification
I confirm that I am the person named above, that I am a member of the Tunica Biloxi Tribe of Louisiana and that I have not filled out this form on another's behalf. I understand that falsifying or failing to provide correct identification information on this form may result in my request not being processed.
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Required
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