Fillable Soboba Band of Luiseo Indians (Soboba Band of Luiseno Indians)

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Soboba Band of Luiseo Indians (Soboba Band of Luiseno Indians)

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Approved/Updated 2/17/16
Soboba Band of Luiseño Indians
P.O. Box 487, San Jacinto, CA 92581 * 951.654.2765
CANCEL PER CAPITA DEDUCTION AUTHORIZATION
IMPORTANT: Completed form must be received by the 15
th
of the month.
All requests received after the 15
th
will not take effect until the following month.
TRIBAL MEMBER INFORMATION
First
Middle
Last
DEDUCTION INFORMATION
Payable to/Name:
Amount being withheld:
$______________________________
I am cancelling this Per Capita deduction effective _____________________. I understand that in order to
(Date)
change the amount I must complete a new Per Capita Deduction Authorization form.
_________________________________________
Signature
_________________________________________
Date
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Soboba Band of Luiseo Indians (Soboba Band of Luiseno Indians)

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Completed 20 July 2020

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