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Code) DAY TIME PHONE NUMBER CITY STATE $ AMOUNT REQUESTING (MAXIMUM $1,000) EMAIL ADDRESS ZIP DATE of BIRTH SOCIAL SECURITY NUMBER (Last 4 digits) PREFERRED CONTACT METHOD (PHONE or E-Mail) PLEASE NOTE: All Per Capita Advances will be disbursed in the same manner that the Tribal member receives their quarterly Per Capita distribution (i.e., manual check or direct deposit). *** Pursuant to Section 7 of the Ho-Chunk Nation amended and restated PER CAPITA DISTRIBUTION ORDINANCE, this ap.

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