b. Do you receive Pension from Shoalwater Bay Tribe?
4. Do you travel more than 60 miles round-trip to work? Yes No
Maximum for this allowance is $25 per week.
Signature of Applicant Date
Any other information or comments:
Information. (**You must sign a Care Provider Verification Form.)
If "Yes", you can deduct medical expenses you paid; you must provide receipts.
a. Are you over 62 years old?
Do you have childcare expenses?
I/We certify that the information given is accurate and complete to the best of my/our
If you had to purchase auxiliary apparatus so a family member could work, you can deduct
the cost you paid; you must provide receipts.
If this person requires attendant care so a family member can work, list Care Provider
Is a household member Handicapped?
If "Yes", list Care Provider Information (**You must sign a Care Provider Verification Form.)
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