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LUMMI NATION UNMET NEEDS DISTRIBUTION INTAKE FORM This form will be used for Lummi Nation internal use only. The information contained on this form is not for distribution to any outside agency or entity. APPLICANT INFORMATION First Name MI Last Name NAME OF LEGAL GUARDIAN/PARENT if minor Mailing Address City State Zip Lummi Enrollment Social Security -- Date of Birth// Phone Number Emergency Contact Name Emergency Contact - CERTIFICATIONS I am or the minor child is a member of Lummi Nation and I or the minor child meets the criteria for basic unmet needs per LIBC Resolution 2016-180. I will use this assistance to meet those unmet needs. I affirm that I am the legal guardian of the minor child and have attached the relevant documentation regarding custody if applicable. By my signature below and acceptance of this ONE-TIME payment I affirm and declaration that all of the above statements are true and accurate. Signature Date All original forms must be turned into the LIBC Treasurers Office either in person or via email* For additional information please contact at the Treasurers Office at 360-312-2094. No checks or gift cards will be released until this form has been received* For minor children and in the event of a dispute gift cards will be withheld until a certified court order identifying custodial rights is received* Any gift cards unlawfully claimed will be voided immediately and subject to prosecution* LIBC shall have no liability for lost or stolen cards once they ve been distributed* Forms can be submitted to Treasurersoffice lumminsn*gov or in person at LIBC. I will use this assistance to meet those unmet needs. I affirm that I am the legal guardian of the minor child and have attached the relevant documentation regarding custody if applicable. By my signature below and acceptance of this ONE-TIME payment I affirm and declaration that all of the above statements are true and accurate. By my signature below and acceptance of this ONE-TIME payment I affirm and declaration that all of the above statements are true and accurate. Signature Date All original forms must be turned into the LIBC Treasurers Office either in person or via email* For additional information please contact at the Treasurers Office at 360-312-2094. Signature Date All original forms must be turned into the LIBC Treasurers Office either in person or via email* For additional information please contact at the Treasurers Office at 360-312-2094. No checks or gift cards will be released until this form has been received* For minor children and in the event of a dispute gift cards will be withheld until a certified court order identifying custodial rights is received* Any gift cards unlawfully claimed will be voided immediately and subject to prosecution* LIBC shall have no liability for lost or stolen cards once they ve been distributed* Forms can be submitted to Treasurersoffice lumminsn*gov or in person at LIBC. I will use this assistance to meet those unmet needs. I affirm that I am the legal guardian of the minor child and have attached the relevant documentation regarding custody if applicable. By my signature below and acceptance of this ONE-TIME payment I affirm and declaration that all of the above statements are true and accurate. Signature Date All original forms must be turned into the LIBC Treasurers Office either in person or via email* For additional information please contact at the Treasurers Office at 360-312-2094. .

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