Updated 07/11/2017
Soboba Band of Luiseño Indians
P.O. Box 487, San Jacinto, CA 92581 * 951.654.2765
PER CAPITA TAX WITHHOLDING AUTHORIZATION
FEDERAL AND STATE TAXES - The minimum required amount will be automatically deducted from your Per Capita
distribution. If you wish to deduct an additional amount, please specify below. This deduction will remain in effect until
an updated form is submitted.
IMPORTANT: The Tribe is required to honor Federal Levy Orders for not filing taxes. If an order is received, the office
will attempt to contact you with the information listed on this form and will process the levy on the next per capita
distribution.
NOTE: Form needs to be submitted by the 15
th
of the month.
TRIBAL MEMBER INFORMATION
First
Middle
Last
SSN
Home Phone
Cell Phone
FEDERAL WITHHOLDING
STATE WITHHOLDING
Please check () one:
Minimum Federal Requirement
Minimum Requirement plus an additional
amount of $________________
__________% (must be over 24% due to fluctuation
of gross income)
Please check () one:
$_______________ (Flat Amount)
____________% (Flat Percentage 13.3% max)
_________________________________________
Signature
_________________________________________
Date
Submit Form
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signature
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