P. O. Box 640 ~ Black River Falls, WI 54615
(715) 284.1660 ~ (800) 779.2873 ~ (715) 284.9972 FAX
Updated:
September 10,
2014
HO-CHUNK NATION
TRIBAL ID # __________
DEPARTMENT OF TREASURY
BUDGETARY ASSISTANCE AUTHORIZATION FORM
Instructions:
1. Enter the last four digits of your tribal ID# above.
3. Complete “
Tribal Member Information
” section below.
NOTE: To opt out of the Monthly Budgetary Assistance Program, select cancel box above. Your
next per capita distribution will revert back to the method prior to enrollment in the Budgetary
Assistance Program.
Tribal Member Information
Name Address Phone Number
Last four digits SSN
XXX-XX-
City, State, Zip Date of Birth
Do you receive SSI or Medicaid?
Email Address (to be used for notification purposes)
Notice: You are not allowed to enroll in this program if you receive SSI or Medicaid
Budgetary Assistance Payments will be disbursed in the same manner as your most recent per capita
distribution.
The form must be submitted 15 calendar days prior to the next quarterly per capita distribution date.
Early payout of any balance remaining does not remove you from future monthly budgetary assistance.
Early payouts may take up to three business days to complete.
I authorize the Ho-Chunk Nation to initiate the selected option regarding my participation in the Budgetary
Assistance Program as indicated above.
__________________________________
__________________________
TRIBAL MEMBER SIGNATURE DATE
This authorization will remain in effect until cancelled. Original, faxed or electronic copies will be accepted.
YES
NO
Enroll
Cancel Participation
Request Partial Payment
Request Remaining Balance
2. Select the option to enroll, cancel or request payment in the top section of this form.
Amount$ ________
***Treasury Use Only***
Date Received:
***Payroll Use Only***
Notice Provided: Date/Initials
Deduction Entered: Date/Initials
_____________/_____
_____________
/_____
