Fillable Salt River Pima Maricopa Indian Community 10005 E. (Salt River Pima-Maricopa Indian Community)

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Salt River Pima Maricopa Indian Community 10005 E. (Salt River Pima-Maricopa Indian Community)

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Effective Date Supersedes Approved
March 31, 2004 NEW March 31, 2004
Page 6 of 6
FUNERAL LOAN APPLICATION
Salt River Pima – Maricopa Indian Community
10005 E. Osborn Rd. Scottsdale, AZ 85256
Phone: (480) 362 – 7400
AMOUNT REQUESTED:
PURPOSE:
NAME OF DECEASED: RELATIONSHIP:
PROJECTED PER CAPITA INCOME THIS YEAR: $
BALANCE OWED FROM A PREVIOUS LOAN: $
I understand that if I receive the loan, I am under obligation to the Salt River Pima-Maricopa
Indian Community in the amount of $ flat fee which is payable from all future Per
Capita income until my debt it paid in full. My Per Capita is not obligated under any Court
Injunction to the SRPMIC Court.
Signature Salt River ID#
Printed Name Date
Address Telephone Number
City, State, Zip Code
APPROVED ____ DENIED ____
Community Official Signature Date
Martin Harvier, President
Print Name and Title of Community Official
PROMISSORY NOTE
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Salt River Pima Maricopa Indian Community 10005 E. (Salt River Pima-Maricopa Indian Community)

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Completed 27 January 2021

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